Discovery of a large axillary artery vascular malformation during the evaluation of a patient with hemodialysis access-induced distal ischemia: Implications on pathophysiology and management

A patient with a 6-year-old left upper arm brachial cephalic AVF presented with symptoms of hemodialysis access-induced distal ischemia (HAIDI). Physical exam findings showed a well-developed AVF, but compression of the AVF aggravated arm pain and induced diffuse erythema of the left upper extremity. Angiographic evaluation disclosed the presence of a large axillary artery vascular malformation (AVM) as well as distal forearm hypo-perfusion. We elected to publish this case report to describe the interesting physical exam findings related to the AVM, and discuss HAIDI treatment options that are peculiar to this case. We also highlight the importance of thorough vascular evaluation prior to AV access creation as well as during the investigation of the cause of HAIDI.