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I appreciate Dr Lee’s comments on my article about massive bleeding from a leg ulcer, probably due to an arteriovenous connection (AVC). He asserts that arteriovenous malformation (AVM) should be considered as the cause of the AVC, and if it were an “extratruncular” lesion, coil embolization could stimulate the progression or recurrence of the disease.1Lee B.B. Do Y.S. Yakes W. Kim D.I. Mattassi R. Hyon W.S. Management of arteriovenous malformations: a multidisciplinary approach.J Vasc Surg. 2004; 39: 590-600Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar He has extensive experience, and his statement is an informative message. The patient in my case, however, did not have a tumor-like lesion like nidus; thus, if the etiology of my case was an AVM, it is unlikely that it was an extratruncular lesion. We now stress the importance of small AVCs in the etiology of severe skin lesions in chronic venous disease. A small AVC can be detected by duplex scans as a small branch (1 to 2 mm in diameter) entering superficial venous systems with a pulsatile wave. In our experience of 500 recent cases of varicose veins, >20% of patients had at least one pulsatile branch. We also reported 18 cases of severe skin lesions (CEAP classification ≥4) for which the etiology was considered to be only small AVCs.2Honda K. Komai H. Juri M. Micro-arteriovenous fistula of the lower extremities with severe skin lesions [Japanese, English abstract].J Jpn Coll Angiol. 2006; 46: 73-78Google Scholar None of our cases had a nidus formation or diffuse infiltration. Judging from our experience, the disease entity that we refer to as a small AVC and Dr Lee’s AVM are likely to be essentially different, or my AVC could be the very early stage of an AVM. Fortunately, the patient I presented has remained well, without any recurrence of a leg ulcer for 15 months after the embolization, which argues against the AVM etiology. A recent duplex scan revealed neither AVM nor venous insufficiency. In respect to what we call a small AVC, our present strategy of embolization appears justified. Further accumulation of knowledge is necessary for a more systematic classification system and effective treatment strategy to be developed for arteriovenous connection in chronic venous disease of the lower extremities. Regarding “Massive spouting bleeding from chronic stasis ulceration caused by arteriovenous communication of the lower extremity”Journal of Vascular SurgeryVol. 45Issue 3PreviewI would like to congratulate the authors Komai et al (J Vasc Surg 2006;44:658-9) for their successful management of potentially life-threatening—if not limb-threatening—venous bleeding. I wholeheartedly agree with their opinion as well as their recommendation. However, I would like to remind the authors and readers together that such massive/recurrent bleeding from the varicose vein that they experienced should arouse the suspicion of a congenital vascular malformation (CVM) as its hidden cause. Full-Text PDF Open Archive