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reported the occurrence of AVF after episodes of deep vein thrombosis &#40;DVT&#41;&#44; particularly in large deep and proximal veins such as the femoral and popliteal veins&#46; After the occlusion of an artery or vein&#44; changes take place with the purpose of redirecting blood flow&#46; In the case of arteries&#44; the new circulation should have the purpose of providing oxygen and nutrition to organs and tissues&#59; this arterial development is known as &#8220;collateralisation&#8221;&#46; For veins&#44; the adjustment is aimed at draining blood&#44; and the term used to describe the new vein formation process is &#8220;neovascularisation&#8221;&#46; While ischaemia is the stimulus for collateral formation&#44; the mechanism responsible for venous neoformation is unclear&#46; In any case&#44; the fact that AVF particularly appear in proximal veins prompts us to ask whether low-resistance flow loss might be the stimulus for neovascularisation more than the thrombosis itself&#46;<span class="elsevierStyleSup">4-6</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical assessment&#58;</span> in most cases of acquired AVF&#44; there are no symptoms and if there are&#44; they may appear within days or months and include thrill in the inguinal area&#44; dyspnoea or new or worsening ischaemia in the limbs&#46; Physical examination of the limb may reveal murmur&#44; thrill&#44; haematoma or pulsatile mass&#46; Oedema&#44; DVT&#44; nerve compression or worsening of previous varicosities may also occur&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Diagnosis&#58;</span> &#160;Doppler is the preferred method of diagnosis&#44; with angiography being used as a therapeutic tool for endovascular treatment&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment&#58; </span><span class="elsevierStyleBold">in </span>small<span class="elsevierStyleBold"> </span>asymptomatic AVF&#44; there is usually spontaneous thrombosis&#44; and they do not require treatment&#44; but treatment is indicated in cases in which symptoms appear&#46; Currently&#44; the techniques of choice are ultrasound-guided compression<span class="elsevierStyleSup">7&#44;8 </span>and percutaneous techniques&#44; with surgery being reserved for selected cases&#44; such as steal syndrome with claudication or significant distal ischaemia of the limb&#44; oedema or venous insufficiency due to venous hypertension&#44; heart failure due to AVF volume&#44; AVF caused by stab wounds or fire and iatrogenic AVF that do not close spontaneously&#46;</p><p class="elsevierStylePara">We report the case of a 58-year-old male with chronic kidney disease of unknown aetiology&#44; on renal replacement therapy since December 2010&#46; He was initially treated with peritoneal dialysis &#40;PD&#41; but was transferred to haemodialysis &#40;HD&#41; in December 2011&#46; This patient had a spontaneous AVF in his left arm&#44; which was eventually used as vascular access&#44; with satisfactory results&#46; The patient came to our clinic in 2007-2008&#44; presenting with advanced renal failure &#40;creatinine 3&#46;5&#44; estimated glomerular filtration rate 20ml&#47;min&#59; immunological study&#44; tumour markers and serologies without findings and chronic ultrasound data&#41;&#46; His medical history showed that he had high blood pressure&#44; was a smoker and had an iliac blade fracture in 1998&#44; after a fall&#44; which required surgery&#46; The physical examination was normal&#44; except for the presence of an exophytic lesion on his upper lip&#44; and he was diagnosed with moderately differentiated squamous-cell carcinoma of the supraglottic larynx and was treated with surgery and coadjuvant radiotherapy&#46; He currently has no diseases and has a tracheostomy that is pending surgical closure&#46; In December 2010&#44; he started PD using a peritoneal catheter&#46; After one month&#44; he developed peritonitis due to <span class="elsevierStyleItalic">Acinetobacter</span>&#44; which resolved with antibiotic treatment&#46; After three months&#44; he had another episode of peritonitis&#44; due to <span class="elsevierStyleItalic">Pseudomona aeruginosa</span>&#44; with several recurrences&#44; which made it necessary to remove the peritoneal catheter and transfer the patient to HD&#46; In February 2012&#44; the patient received a new peritoneal catheter and on starting the technique&#44; a peritoneal-pleural leak occurred with secondary massive pleural effusion&#44; and he was permanently transferred to HD&#46;</p><p class="elsevierStylePara">With regard to the vascular access&#44; in November 2011&#44; the patient received a left jugular dual lumen tunnelled catheter for HD&#46; After six months&#44; he presented with progressive oedema in his left arm&#44; and a radiological study &#40;venogram&#41; was therefore requested&#44; which displayed thrombosis in the patient&#8217;s left distal subclavian vein&#44; brachiocephalic artery and left distal jugular vein&#46; A thrombectomy was performed and we observed substantial improvement&#44; although partial thrombosis remained in the brachiocephalic artery and left jugular vein&#46; In the same operation&#44; the jugular catheter was removed and replaced with a permanent left femoral catheter&#44; with anticoagulation being introduced orally&#46; A month after we detected thrombosis&#44; in an operation to introduce an AVF&#44; we detected a pulse and thrill in the patient&#8217;s left forearm&#44; and after he was assessed by the vascular surgeon clinically and with a Doppler ultrasound of the arm&#44; we found that the pulse and thrill were due to an AVF that was suitable for use in HD&#46; A fistulogram was performed&#44; which showed the presence of a humeral AVF&#44; which was punctured without difficulties&#44; with adequate suction and entry pressure&#44; recirculation &#60;10&#37; and adequate dialysis doses&#59; the situation remains the same at present&#46;</p><p class="elsevierStylePara">The interest of this case lies in the fact that spontaneous AVF in the arms are extremely uncommon&#44; and furthermore&#44; in this case the AVF was very useful&#46; Risk factors include high blood pressure&#44; a history of numerous punctures for blood samples&#44; brachiocephalic artery thrombosis and anticoagulation&#44; initiated as a result of this&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11971&#95;16025&#95;54640&#95;en&#95;f111971&#46;jpg" class="elsevierStyleCrossRefs"><img src="11971_16025_54640_en_f111971.jpg" alt="Left femoral arteriovenous fistula&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Left femoral arteriovenous fistula&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11971&#95;16025&#95;54641&#95;en&#95;f211971&#46;jpg" class="elsevierStyleCrossRefs"><img src="11971_16025_54641_en_f211971.jpg" alt="Fistulogram&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Fistulogram&#46;</p>"
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