title: Thinking outside the box: a middle-aged man with new-onset dyspnoea on exertion and pedal oedema.
abstract: We describe a diagnostic dilemma in a middle-aged man presenting with dyspnoea and bilateral pedal oedema who had been diagnosed with right heart failure based on clinical evidence. The evaluation for aetiology eventually led to discovery of an unusual extrathoracic cause, a left-to-right communication in the renal vasculature. Renal arteriovenous fistulae are rare and can be congenital, acquired or idiopathic. A left-to-right shunt typically presents with high-output cardiac failure involving the left and right sides of the heart. An atypical feature of this case was the finding of overt right heart failure in the setting of a normal left heart. Such a presentation has only been described in a few isolated case reports. Diagnostic approaches include CT angiography and cardiac catheterisation for haemodynamic measurements. The primary treatment options for arteriovenous fistulae are medical management, arterial embolisation and surgical repair.
authors.affiliation: Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Yogita M
authors.initials: YM
authors.lastname: Rochlani
authors.affiliation: Department of Medicine-Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Vidya B
authors.initials: VB
authors.lastname: Pai
authors.affiliation: Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Abdel Rahman M
authors.initials: AR
authors.lastname: Lataifeh
authors.affiliation: Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Thaddeus
authors.initials: T
authors.lastname: Bartter
mesh_terms: D000792:Angiography / Q000379:methods*; D001164:Arteriovenous Fistula / Q000150:complications* / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D006328:Cardiac Catheterization; D004417:Dyspnea / Q000209:etiology; D004487:Edema / Q000209:etiology; D005528:Foot / Q000473:pathology; D006333:Heart Failure / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000209:etiology*; D006801:Humans; D007668:Kidney / Q000098:blood supply* / Q000000981:diagnostic imaging / Q000473:pathology; D008297:Male; D008875:Middle Aged; D005082:Physical Exertion; D014057:Tomography, X-Ray Computed