Lower-Extremity Arteriovenous Malformation Masquerading as Peripheral Artery Disease

An arteriovenous malformation (AVM) refers to an anomalous, direct connection between an artery and a vein. Typically, these two vessels are interposed by high-resistance capillary beds, the absence of which results in a high-flow system from an artery into a vein. Venous vessel walls are not designed to handle such high-pressure blood flow, and their vessel wall structure becomes permanently altered and weakened. For this reason, AVMs are at an increased risk for hemorrhages and ruptures. AVMs present with a spectrum of symptoms, ranging from skin discoloration, ischemia in distal tissues, and heart failure from arteriovenous shunting. Here, we present a case of a patient who underwent amputation of his second left toe, initially thought to be a result of peripheral arterial disease (PAD) due to his extensive smoking history. Further imaging findings revealed a rare lower-extremity AVM as the source of his ischemia, not PAD. Ultimately, the treatment of the vascular anomaly and resolution of the patient's symptoms were achieved via transarterial embolization. This case emphasizes the importance of looking beyond PAD as the cause of distal lower-extremity ischemia and provides insights into an uncommon and often missed diagnosis of extracranial AVMs.