The subcutaneous defibrillator will replace the transvenous defibrillator

Venous Hemodialysis Catheters and Cardiac Implantable Electronic Devices: Avoiding a High-Risk Combination

End-stage renal disease is frequently accompanied by cardiac comorbidity that warrants treatment with a cardiovascular implantable electronic device (permanent pacemaker or implantable cardioverter-defibrillator). In the United States, chronic hemodialysis (HD) population, cardiac implantable devices are present in up to 10.5% of patients; a venous HD catheter is utilized for blood access in 18% of prevalent patients. The concomitant presence of a venous HD catheter and cardiovascular implantable device creates a high-risk circumstance, with potential for causing symptomatic central venous stenosis, and for developing complicated endovascular infection. This dangerous combination may be avoided for many patients by utilizing nondialysis methods for management of advanced chronic kidney disease, initiating dialysis without venous catheter access, or managing cardiac rhythm disorders without use of transvenous cardiac implantable electronic devices. In those situations where the combination of a venous HD catheter and cardiac implantable device is unavoidable, there are strategies to minimize duration of venous catheter access, and to reduce risks for infectious complications. It is essential for nephrologists and cardiologists to understand the indications, alternatives, and risks involved with venous HD access and cardiac implantable devices. Coordinated management of renal disease and cardiac rhythm disorders has potential to minimize risks, improve outcomes, and substantially reduce the cost of care.

Cardiovascular implantable electronic devices in hemodialysis patients: prevalence and implications for arteriovenous hemodialysis access interventions

Cardiovascular implantable electronic devices (CIEDs) are frequently utilized in hemodialysis patients. CIED leads are typically implanted via the subclavian vein resulting in stenosis and venous hypertension. We studied 1235 chronic hemodialysis patients under the care of our nephrology practice. For each, we determined the presence of a CIED, indication for implantable cardioverter-defibrillator (ICD), and type of hemodialysis access. Records were reviewed to identify all interventions performed on the access circuit and the central veins specifically. A CIED was present in 129 patients (10.5%), including ICDs in 75 (6.1%) and pacemakers in 54 (4.4%). The access circuit intervention rate was 1.48/access year (AY) and was similar when a CIED was ipsilateral (1.53/AY) or contralateral (1.44/AY) to arteriovenous access (p = 0.477). The rate of central venous interventions was greater in the ipsilateral (0.59/AY) versus contralateral group (0.28/AY), (p < 0.001). Fifty-four of 59 patients with ipsilateral access and CIED required <2 interventions per AY, but six failed angioplasty and required access ligation. None had superior vena cava stenosis requiring intervention. We conclude that there is a high prevalence of CIEDs in our HD patients. Ipsilateral CIED and arteriovenous access results in higher central venous intervention rates compared with contralateral cases; overall access circuit intervention rates are similar.