Dear Ersan Tatli,

Probably an Traumatic AVF.There is any traumatic or invasive (puncture) hystory?  .

I would try the endovascular approach and treatment with endograft if possible (small size arteries) need to study better the images in another incidence or in last case hibrid access.

Dear Tatlı.

Great case. Congregulations.  

I suppose it would be congeninal.  But, some surgical fistulas may also cuase that picture. We a similar case with congenital aetioligy 6 months earlier in Popliteal atery to venous system. There was many small fistulous connections. We searched a big origin but it was apsent. So, we have implanted  three graft stents. Leg swelling subsided but little fistulas remained about 10 % of the beginning. 

Surgixal approach will be generally un-succesfull in your case. I recommend the endovascular graft stenting first. 

Long perfusion balloon implantation for at least one month and removing it may also cayse thrombotic occlusion of small fistula arteries.

Finally, this a challenging case and excellent.

You have mentioned 'unhealing' wound, in my opinion that is the key. The angiograph does not show any well defined fistula. I shall investigate the cause of 'unhealing' wound and whether there is some chronic infection and try to to find its cause before deciding on surgical interference.

Dear colleague

I think that regardless of the origin  of the fistula (which will be clarified in a second time) the best think to do is closing it with  endovascular approach.

Then I will treat the wound that seems to be superinfected

The patient is somewhat older. I think this treatment is  a last chance for the patient to achive complete surgical excision, reconstruction by free flap, and rehabilitation to get  useable hand. This is one option among many treatments for a difficult case.

I am excluding he congenital origin at this age, it could be a posttraumatic AVF, or an intramuscular haemangioma, I had a similar case that was treated successfully by simple multiple ligations.