Endovenous Laser Ablation of Pathological Arteriovenous Fistulas for Recurrent Lower Limb Cellulitis: A Retrospective Observational Study

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Objective Pathological arteriovenous fistulas (AVFs) in the foot have been proposed as a treatable vascular cause of antibiotic-refractory recurrent lower-limb cellulitis, but clinical evidence remains limited. We report clinical phenotype, procedural outcomes, and recurrence-free survival after endovenous laser AVF ablation. Methods This retrospective observational study included 57 consecutive patients who underwent duplex-guided endovenous laser ablation for recurrent lower-limb cellulitis-mimicking inflammatory episodes (January 2015–December 2024). Inclusion criteria were ≥2 prior cellulitis episodes, absence of fever, negative microbiological workup, and duplex-confirmed AVF. The primary outcome was Kaplan–Meier recurrence-free survival. The association between calcium channel blocker (CCB) discontinuation and recurrence was evaluated using Fisher's exact and log-rank tests. Results Mean age was 73.7±11.2 years (64.0% female). The inflammatory profile at presentation was consistent with a non-infectious mechanism: history of fever in 8.0%, mean WBC 6,501±1,853/μL, median CRP 0.26 mg/dL; all blood cultures were negative. Hypertension was present in 86.0%, with 86.0% receiving CCBs. Recurrence-free survival was 100% at 12 months and 79.3% (95% CI: 57.8–90.6%) at 60 months. All 12 recurrences occurred after 12 months. Among CCB users, the recurrence rate was 3.3% in those whose CCBs were discontinued versus 47.4% in those unchanged (p<0.001); 60-month recurrence-free survival was 100% versus 51.5% (log-rank p=0.003). Conclusions Endovenous laser ablation of pathological AVFs achieved recurrence-free survival in approximately 80% of patients at five years. The presentation consistent with a non-infectious mechanism, exclusively late-onset recurrence, and marked reduction in recurrence with CCB discontinuation support an AVF-driven vascular mechanism. Duplex evaluation for AVFs should be considered in antibiotic-refractory recurrent lower-limb cellulitis.