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Gerrickens MW, Yadav R, Vaes RH, Scheltinga MR. A scoping review on surgical reduction of high flow arteriovenous haemodialysis access. J Vasc Access 2024; 25:728-744. [PMID: 36428291 DOI: 10.1177/11297298221138361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Volume flow (Qa) > 1.5-2 l /minQa in arteriovenous accesses may be associated with high flow related systemic or locoregional complications. A variety of surgical techniques are advocated for Qa reduction. Aim of this scoping review is to provide an overview of available evidence regarding the efficacy of this broad spectrum of interventions for Qa reduction in patients with a high flow haemodialysis access. PubMed and Embase were searched according to PRISMA-guidelines. Studies on invasive management of HFA were selected. Inclusion required an English description of surgical techniques in human HFAs including pre- and postoperative access flow-values. Sixty-six studies on 940 patients (mean age 56 years (3-90 years), male 62%, diabetes mellitus 26%, brachial artery-based arteriovenous access 65%) fulfilled inclusion criteria. Performed techniques were banding (58%), revision using distal inflow (12%), plication/anastomoplasty (10%), graft interposition (5%), proximal radial artery ligation (3%), aneurysm repair (4%), or miscellaneous other techniques (8%). Definition of HFA, work-up, indication for surgery and intraoperative monitoring were diverse. All techniques reduced Qa on the short term (mean drop 0.9-1.7 l/min). Secondary access patency rates varied between 70% and 93% (mean follow-up 15 (0-189) months). Definitions of success and recurrence varied widely precluding a comparison of efficacy of techniques. Patient specific factors legitimizing invasive treatment for HFA are discussed. Recommendations on reporting standards when dealing with HFA surgery are provided. In conclusion, the present report on the current management of high flow access does not allow for drawing any definite conclusions due to a lack of standardization in definition, indications for surgical intervention and techniques. Randomized trials comparing different Qa reducing techniques in symptomatic patients are warranted, as are trials comparing a wait-and-see approach versus Qa reduction in asymptomatic patients. As an overview of the variety of techniques was lacking, this scoping review might serve as a map for future researchers.
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Affiliation(s)
| | - Reshabh Yadav
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Roel Hd Vaes
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Marc Rm Scheltinga
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
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2
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Matoussevitch V, Kalmykov E, Shahverdyan R. Novel external stenting for reconstruction of high flow arteriovenous fistula. J Vasc Access 2022; 23:864-870. [PMID: 33971759 DOI: 10.1177/11297298211015508] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High-flow arteriovenous fistulae (HF-AVF) may lead to adverse cardiac remodeling in hemodialysis patients. We have investigated whether a novel external stent is safe and effective in reducing and stabilizing flow rates during a 1-year follow-up after HF-AVF reconstruction. METHODS All patients with HF-AVF (access flow rate ⩾ 1500 ml/min), who underwent HF-AVF reconstruction with external stenting in two centers between June 2018 and May 2020, were included in this retrospective analysis. During HF-AVF reconstruction, the dilated vein segment was resected, underwent volume reduction, and was externally stabilized using a braided cobalt-chromium external stent. AVF flow rates were assessed preoperatively, intraoperatively, and at follow up visits using duplex ultrasound. RESULTS Forty-three HF-AVFs in 42 patients were reconstructed and supported with an external stent (mean age 49 years, range 20-86 years; 74% men). Fifty-one percent were forearm AVFs, 49% were upper arm. The mean preoperative flow rate was 2622 ± 893 ml/min (range: 1500-6000 ml/min) and was decreased to 710 ± 221 ml/min (range: 300-1300 ml/min) intra-operatively after HF-AVF reconstruction. At 6 and 12-months follow-up, the mean flow rates were 1132 ± 320 ml/min (range: 470-1700 ml/min) and 1453 ± 888 ml/min (range: 300-3800 ml/min), respectively. Recurrence of high flow (>1500 ml/min) occurred in 16% and 25% of the patients at 6 and 12 months and primary patency rates were 86% and 70%, respectively. CONCLUSIONS This early experience with novel external stenting for HF-AVF reconstruction demonstrates that it is a safe and effective method for reducing and stabilizing flow rates up to 1-year post procedure. Additional studies are required to evaluate the durability of this procedure over the longer term and assess its effect on cardiac remodeling.
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Affiliation(s)
- Vladimir Matoussevitch
- Vascular Access Unit, Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Egan Kalmykov
- Vascular Access Unit, Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Nordrhein-Westfalen, Germany
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Yadav R, Gerrickens MWM, van Kuijk SMJ, Vaes RHD, Snoeijs MGJ, Scheltinga MRM. Access flow volume (Qa) and survival in a hemodialysis population: An analysis of 5208 Qa measurements over a 9-year period. Nephrol Dial Transplant 2021; 37:1751-1757. [PMID: 34383950 DOI: 10.1093/ndt/gfab242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Aim of the study was to determine associations between characteristics of arteriovenous access (AVA) access flow volume (Qa, mL/min) and four year freedom from cardiovascular mortality (4yr-CVM) in hemodialysis (HD) patients. METHODS HD patients who received a primary AVA between January 2010 and December 2017 in one center were analyzed. Initial Qa was defined as the first Qa value obtained in a well-functioning AVA by a two-needle dilution technique. Actual Qa was defined as access flow at a random point of time. Changes in actual Qa were expressed per 3-month periods. CVM was assessed according to the ERA-EDTA classification. The optimal cut-off point for initial Qa was identified by a receiver operating characteristic curve. A joint modelling statistical technique determined longitudinal associations between Qa characteristics and 4yr-CVM. RESULTS A total of 5208 Qa measurements (165 patients, male n = 103; age 70±12 years, autologous AVA n = 146, graft n = 19) were analyzed. During follow-up (Dec 2010-Jan 2018, median 36 months), 79 patients (48%) died. An initial Qa < 900 mL/min was associated with an increased 4y-CVM risk (HR: 4.05; 95% CI [1.94-8.43], P<0.001). After 4 years, freedom from CVM was 34% lower in patients with a Qa < 900 mL/min (53 ±7% vs. Qa ≥ 900 mL/min: 87 ±4%, P <0.001). An association between increases in actual Qa over 3-month periods and mortality was found (HR: 4.48 per 100mL/min, 95% CI [1.44-13.97], P =0.010) indicating that patients demonstrating increasing Qa were more likely to die. By contrast, actual Qa per se was not related to survival. CONCLUSIONS Studying novel arteriovenous access Qa characteristics may contribute to understanding excess CVM in HD patients.
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Affiliation(s)
- Reshabh Yadav
- Department of Surgery, Máxima MC, Veldhoven, The Netherlands
| | | | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roel H D Vaes
- Department of Surgery, Máxima MC, Veldhoven, The Netherlands
| | - Maarten G J Snoeijs
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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4
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Late Basilic Vein Superficialization Combined with Revision Using Distal Inflow (RUDI) Operation to Treat a Symptomatic High Flow Fistula. Ann Vasc Surg 2021; 74:502-510. [PMID: 33831516 DOI: 10.1016/j.avsg.2021.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Vascular access (VA)-related high flows (HF) are common with brachial artery based fistulas. Flow-reduction procedures are indicated in symptomatic patients or asymptomatic ones with flows >2 L/min. However concomitant issues increase their complexity. We describe a case of a patient suffering congestive heart failure as a result of HF brachial-basilic fistula >3 L/min. A simultaneous late basilic vein transposition and revision using distal inflow (RUDI) was performed. METHODS A large diameter untransposed arterialized basilic vein was carefully and completely mobilized up to the proximal upper arm. After harvesting an autologous great saphenous vein (GSV) segment, a new inflow anastomosis was performed in the proximal ulnar artery. At the final stage, and after tunneling the mobilizing basilic vein in a subcutaneous semicircular configuration, an end-to-end anastomosis joining the two stumps (basilic vein outflow portion and GSV inflow arterial portion) was performed. A decision-making process in order to reach this complex option is discussed. Results Access flow and cardiac output were greatly attenuated following our approach. After a mean follow-up of 9 months no VA complications were observed, with flow still detected below 2 L/min. All cardiac symptoms and ultrasound investigations improved. CONCLUSION Multiple VA issues including HF pose a risk for abandonment and a challenge for the vascular surgeon. An effort toward increasing the "upper extremity life span" is advised.
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Rivera Gorrín M, Sosa Barrios RH, Ruiz-Zorrilla López C, Fernández JM, Marrero Robayna S, Ibeas López J, Salgueira Lazo M, Moyano Franco MJ, Narváez Mejía C, Ceballos Guerrero M, Calabia Martínez J, García Herrera AL, Roca Tey R, Paraíso Cuevas V, Merino Rivas JL, Abuward Abu-Sharkh I, Betriu Bars À. Consensus document for ultrasound training in the specialty of Nephrology. Nefrologia 2020; 40:623-633. [PMID: 32773327 DOI: 10.1016/j.nefro.2020.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/15/2020] [Accepted: 05/10/2020] [Indexed: 12/26/2022] Open
Abstract
Ultrasound is an essential tool in the management of the nephrological patient allowing the diagnosis, monitoring and performance of kidney intervention. However, the usefulness of ultrasound in the hands of the nephrologist is not limited exclusively to the ultrasound study of the kidney. By ultrasound, the nephrologist can also optimize the management of arteriovenous fistula for hemodialysis, measure cardiovascular risk (mean intimate thickness), implant central catheters for ultrasound-guided HD, as well as the patient's volemia using basic cardiac ultrasound, ultrasound of the cava inferior vein and lungs. From the Working Group on Interventional Nephrology (GNDI) of the Spanish Society of Nephrology (SEN) we have prepared this consensus document that summarizes the main applications of ultrasound to Nephrology, including the necessary basic technical requirements, the framework normative and the level of training of nephrologists in this area. The objective of this work is to promote the inclusion of ultrasound, both diagnostic and interventional, in the usual clinical practice of the nephrologist and in the Nephrology Services portfolio with the final objective of offering diligent, efficient and comprehensive management to the nephrological patient.
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Affiliation(s)
| | | | | | | | | | - José Ibeas López
- Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España
| | | | | | | | | | | | | | - Ramón Roca Tey
- Hospital de Mollet, Mollet del Vallés, Barcelona, España
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Kovarova L, Valerianova A, Michna M, Malik J. Short-term manual compression of hemodialysis fistula leads to a rise in cerebral oxygenation. J Vasc Access 2020; 22:90-93. [PMID: 32489138 DOI: 10.1177/1129729820924561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Decreased cerebral perfusion and oxygenation are common in hemodialysis patients. Magnitude of the arteriovenous fistula involvement in this phenomenon is not known. The aim of this study was to investigate the effect that a short-term arteriovenous fistula flow interruption has on cerebral oxygenation and to review and suggest possible explanations. METHODS In 19 patients, basic laboratory and clinical data were obtained and arteriovenous fistula flow volume was measured by ultrasonography. Baseline regional cerebral oxygen saturation (rSO2) was measured by near-infrared spectroscopy. Manual pressure was then applied on the fistula, resulting in total blood flow interruption. After 1 min of manual compression, rSO2 and blood pressure values were noted again. The compression-related change in rSO2 was assessed, as well as its association with arteriovenous fistula flow volume, blood pressure, and other parameters. RESULTS Mean cerebral rSO2 increased after arteriovenous fistula compression (from 53.6% ± 11.4% to 55.6% ± 10.8%; p = 0.000001; 95% confidence interval = 1.39-2.56). The rSO2 increase was higher in patients with lower rSO2 at baseline (r = -0.46; p = 0.045). CONCLUSION A significant rise in cerebral oxygenation was observed following the manual compression of arteriovenous fistula. Therefore, the arteriovenous fistula could have a role in impaired cerebral oxygenation in hemodialysis patients.
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Affiliation(s)
- Lucie Kovarova
- Third Department of Internal Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Anna Valerianova
- Third Department of Internal Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Michna
- Department of Radiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jan Malik
- Third Department of Internal Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Gerrickens MW, Vaes RH, Wiersma V, van Kuijk SM, Snoeijs MG, Govaert B, Scheltinga MR. Revision using distal inflow for high flow hemodialysis access alters arterial flow characteristics in the dialysis arm. J Vasc Surg 2020; 71:920-928. [DOI: 10.1016/j.jvs.2019.06.197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/19/2019] [Indexed: 12/11/2022]
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Scholz SS, Böhm M, Mahfoud F. Arteriovenous Fistula, Blood Pressure, and Shunt Flow: A Thin Line That Separates Beneficial From Detrimental Effects. Am J Hypertens 2019; 32:935-937. [PMID: 31179486 DOI: 10.1093/ajh/hpz094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sean S Scholz
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Oprea A, Molnar A, Scridon T, Mircea PA. Digital pressure in haemodialysis patients with brachial arteriovenous fistula. Indian J Med Res 2019; 149:376-383. [PMID: 31249203 PMCID: PMC6607816 DOI: 10.4103/ijmr.ijmr_415_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives : The pathophysiological mechanisms involved in distal pressure changes following arteriovenous fistula (AVF) creation in patients with end-stage renal disease (ESRD) are not completely understood. This study was aimed to assess digital pressure changes post-AVF creation and to identify the factors that might influence these changes in ESRD patients. Methods : In this prospective study, 41 patients with ESRD underwent AVF creation. Basal digital pressure (BDP), digital brachial index (DBI), calcium, phosphorus and blood urea levels were assessed preoperatively. BDP, DBI, vein and artery diameters, and AVF blood flow were also evaluated at one and two month(s) post-AVF creation. Results : Mean BDP significantly decreased from 131.64±25.86 mmHg (baseline) to 93.15±32.14 and 94.53±32.90 mmHg at one and two months post-AVF creation, respectively (P <0.001). Mean DBI significantly decreased one month post-AVF creation versus baseline (0.70±0.18 vs. 0.89±0.17 mm, P <0.001) and remained similar at two versus one month(s) postoperatively (0.70±0.23 vs. 0.70±0.18 mm). At both postoperative timepoints, no correlation between DBI decrease and increased artery and vein diameters or fistula blood flow was observed. Mean DBI difference between patients with previous ipsilateral access versus those without was not significant from pre to one month postoperatively. No correlation was observed between baseline phosphorus, calcium and blood urea nitrogen and DBI changes. Interpretation & conclusions : Our findings suggest that decrease in distal pressure following AVF creation may not be influenced by the arterial remodelling degree, vein diameter or fistula flow. In uraemic patients, those with low calcium and/or increased phosphorus, no association between these parameters and DBI changes could be observed.
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Affiliation(s)
- Alexandru Oprea
- Department of Cardiovascular Surgery, "Niculae Stancioiu" Heart Institute, Cluj-Napoca, Romania
| | - Adrian Molnar
- Department of Cardiovascular Surgery, "Niculae Stancioiu" Heart Institute, Cluj-Napoca, Romania
| | - Traian Scridon
- Department of Cardiovascular Surgery, "Niculae Stancioiu" Heart Institute, Cluj-Napoca, Romania
| | - Petru Adrian Mircea
- Department of Gastroenterology, Emergency Clinical County Hospital, University of Medicine & Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
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Scholz SS, Vukadinović D, Lauder L, Ewen S, Ukena C, Townsend RR, Wagenpfeil S, Böhm M, Mahfoud F. Effects of Arteriovenous Fistula on Blood Pressure in Patients With End-Stage Renal Disease: A Systematic Meta-Analysis. J Am Heart Assoc 2019; 8:e011183. [PMID: 30764686 PMCID: PMC6405662 DOI: 10.1161/jaha.118.011183] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/11/2019] [Indexed: 01/21/2023]
Abstract
Background Central arteriovenous fistula ( AVF ) creation is under investigation for treatment of severe hypertension. We evaluated the effects of AVF for initiation of hemodialysis on systolic, diastolic, and mean arterial blood pressure in patients with end-stage renal disease. Methods and Results Data search included PubMed, Web of Science, and the Cochrane Library. A systematic review and meta-analysis of peer-reviewed studies reporting the effects of the creation/ligation of an AVF on blood pressure in patients with end-stage renal disease was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis), PRISMA -P (PRISMA for systematic review protocols), and ROBINS-I (Risk of Bias in Non-Randomized Studies) criteria by the Cochrane Bias Methods Group. All studies in which the results could have been biased by hemodialysis were excluded. A total of 14 trials including 412 patients with end-stage renal disease ( AVF creation, n=185; AVF ligation, n=227) fulfilled the criteria and were subsequently analyzed. Average blood pressure in patients with no/closed AVF was 140.5/77.6 mm Hg with a mean arterial blood pressure of 96.1 mm Hg. Following creation of AVF , systolic blood pressure significantly decreased by 8.7 mm Hg ( P<0.001), diastolic blood pressure by 5.9 mm Hg ( P<0.001), and mean arterial blood pressure by 6.6 mm Hg ( P=0.02), whereas after ligation systolic blood pressure increased by 5.2 mm Hg ( P=0.07), diastolic blood pressure by 3.8 mm Hg ( P=0.02), and mean arterial blood pressure by 3.7 mm Hg ( P=0.07) during short- to long-term follow-up. Conclusions Creation of AVF significantly decreases blood pressure in patients with end-stage renal disease, whereas blood pressure tends to increase after ligation. These findings illustrate the hemodynamic consequences of AVF which are under investigation for severe hypertension.
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Affiliation(s)
- Sean S. Scholz
- Klinik für Innere Medizin IIIKardiologie, Angiologie und Internistische IntensivmedizinSaarland University HospitalHomburg/SaarGermany
| | - Davor Vukadinović
- Klinik für Innere Medizin IIIKardiologie, Angiologie und Internistische IntensivmedizinSaarland University HospitalHomburg/SaarGermany
| | - Lucas Lauder
- Klinik für Innere Medizin IIIKardiologie, Angiologie und Internistische IntensivmedizinSaarland University HospitalHomburg/SaarGermany
| | - Sebastian Ewen
- Klinik für Innere Medizin IIIKardiologie, Angiologie und Internistische IntensivmedizinSaarland University HospitalHomburg/SaarGermany
| | - Christian Ukena
- Klinik für Innere Medizin IIIKardiologie, Angiologie und Internistische IntensivmedizinSaarland University HospitalHomburg/SaarGermany
| | - Raymond R. Townsend
- Perelman School of MedicineUniversity of Pennsylvania Medical CenterPhiladelphiaPA
| | - Stefan Wagenpfeil
- Institut für Medizinische BiometrieEpidemiologie und Medizinische Informatik (IMBEI)Saarland UniversityCampus Homburg/SaarGermany
| | - Michael Böhm
- Klinik für Innere Medizin IIIKardiologie, Angiologie und Internistische IntensivmedizinSaarland University HospitalHomburg/SaarGermany
| | - Felix Mahfoud
- Klinik für Innere Medizin IIIKardiologie, Angiologie und Internistische IntensivmedizinSaarland University HospitalHomburg/SaarGermany
- Institute for Medical Engineering and ScienceMassachusetts Institute of TechnologyCambridgeMA
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Laranjinha I, Matias P, Oliveira R, Casqueiro A, Bento MT, Carvalho AP, Adragão T, Jorge C, Bruges M, Birne R, Machado D, Weigert A. The impact of functioning hemodialysis arteriovenous accesses on renal graft perfusion: Results of a pilot study. J Vasc Access 2018; 20:482-487. [DOI: 10.1177/1129729818817248] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Introduction: After a kidney transplant, it is unknown whether the maintenance of a functioning hemodialysis arteriovenous access could have deleterious effects on renal grafts. We hypothesize that maintaining an arteriovenous access can deviate a significant proportion of the cardiac output from the renal graft. The aim of this study was to investigate whether a temporary closure of the arteriovenous access could lead to an increase in graft perfusion. Methods: We conducted a study in 17 kidney-transplanted patients with a functioning arteriovenous access. We evaluated, at baseline and 30 s after compression of the arteriovenous access (access flow occlusion), the hemodynamic parameters and the renal resistive index of the graft by Doppler ultrasound. Results: After arteriovenous access occlusion 82.4% (n = 14) of the patients had a decrease in resistive index. All patients had a decrease in heart rate (67 vs 58 bpm, p < 0.001) and 14 (82.4%) had an increase in mean blood pressure (98.3 vs 101.7 mm Hg, p = 0.044). There was a significant decrease in the resistive index (ΔRI) after the access occlusion (0.68 vs 0.64, p = 0.030). We found a negative correlation in Qa (r2 = −0.55, p = 0.022) with the ΔRI, and Qa was an independent predictor of ΔRI in a model adjusted to pre-occlusion resistive index. Conclusion: Our results showed that temporary occlusion of an arteriovenous access causes a significant decline in renal graft resistive index and this decline is higher with the occlusion of accesses with higher Qa. These results suggest that the maintenance of arteriovenous accesses, mainly those with higher Qa, can decrease renal graft perfusion.
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Affiliation(s)
- Ivo Laranjinha
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Patricia Matias
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- Nova Medical School – Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Regina Oliveira
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Ana Casqueiro
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Maria Teresa Bento
- Department of Radiology, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Ana Paula Carvalho
- Department of Radiology, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Teresa Adragão
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- Nova Medical School – Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Cristina Jorge
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Margarida Bruges
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Rita Birne
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Domingos Machado
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - André Weigert
- Kidney Transplant Unit, Nephrology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- Faculdade de Medicina, University of Lisbon, Lisbon, Portugal
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Aala A, Sharif S, Parikh L, Gordon PC, Hu SL. High-Output Cardiac Failure and Coronary Steal With an Arteriovenous Fistula. Am J Kidney Dis 2018; 71:896-903. [DOI: 10.1053/j.ajkd.2017.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 10/07/2017] [Indexed: 11/11/2022]
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A Report of Two Cases of Hazards Associated with High Flow Arteriovenous Fistula in ESRD Patients. Case Rep Nephrol 2018; 2018:1686135. [PMID: 29850309 PMCID: PMC5914151 DOI: 10.1155/2018/1686135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 11/18/2022] Open
Abstract
High flow arteriovenous fistulas are a common clinical entity affecting patients with end-stage renal failure receiving hemodialysis. Given the difficulty in predicting who will develop a high flow arteriovenous fistula the exact prevalence is unclear. We present two cases of patients with high flow arteriovenous fistula that developed clinical cardiac failure at a time point after the fistula was placed with findings of significant cephalic arch stenosis. Both patients required treatment of cephalic arch stenosis with balloon angioplasty with subsequent surgical aneurism resection. Accurate and timely diagnosis of high flow arteriovenous hemodynamics by prospective monitoring of volumetric flow and cardiac function is required to halt this process prior to cardiac compromise.
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Gerrickens MW, Vaes RH, Govaert B, van Loon M, Tordoir JH, van Hoek F, Teijink JA, Scheltinga MR. Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous Fistula. Eur J Vasc Endovasc Surg 2018; 55:874-881. [DOI: 10.1016/j.ejvs.2018.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/10/2018] [Indexed: 10/17/2022]
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15
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Tissue ischemia worsens during hemodialysis in end-stage renal disease patients. J Vasc Access 2016; 18:47-51. [PMID: 27886367 DOI: 10.5301/jva.5000630] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cognitive deficit is a common problem in end-stage renal disease (ESRD) patients. Ultrafiltration and hemodialysis lead to profound hemodynamic changes. The aim of this pilot study was to describe brain and hand oxygenation values in ESRD patients and their changes during hemodialysis. METHODS Twenty-seven patients treated by chronic hemodialysis and 17 controls patients of the same age were included in the study. Regional saturation of oxygen (SrO2) was measured at the brain frontal lobe and at the hand with dialysis access using the INVOS 5100C. In 17 of ESRD patients, SrO2 was also monitored throughout hemodialysis. Finger systolic blood pressure and basic hemodialysis and laboratory data were collected. RESULTS Dialysis patients had lower brain and also hand SrO2 values at rest (51.5 ± 10.9 vs. 68 ± 7%, p<0.0001 and 55 ± 16 vs. 66 ± 8%, p = 0.03, respectively). Both values further decreased during the first 35 minutes of hemodialysis (brain SrO2 to 47 ± 8%, p<0.0001 and hand to 45 ± 14%, p<0.0001, respectively). The brain SrO2 decrease was related to the ultrafiltration rate, the hand SrO2 decrease to the finger pressure and to blood hemoglobin. CONCLUSIONS Chronic dialysis patients suffer from tissue ischemia and that even worsens after the beginning of hemodialysis. This observation may contribute to the understanding of cognitive deficit etiology.
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Yilmaz S, Yetim M, Yilmaz BK, Dogan T, Aksoy E, Yuksel N, Dogan I. High hemodialysis vascular access flow and impaired right ventricular function in chronic hemodialysis patients. Indian J Nephrol 2016; 26:352-356. [PMID: 27795630 PMCID: PMC5015514 DOI: 10.4103/0971-4065.164232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
There are limited data showing right ventricular preload increase due to high-flow arteriovenous fistulas (AVFs). This cross-sectional study investigated whether high AVF flow had an impact on right ventricular function in patients undergoing hemodialysis. Sixty-four patients aged between 18 and 85 years who were on routine hemodialysis with >2 hemodialysis sessions per week for at least 3 months via an AVF were studied. Patients with inadequate flow fistulas, severe chronic obstructive pulmonary disease, history of pulmonary embolism, primary pulmonary hypertension, severe mitral, aortic or pulmonary regurgitation, and/or stenosis were excluded. After an initial evaluation, 44 patients (mean age: 58.50 ± 16.84, male:female = 23:21) were considered eligible. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE). AVF blood flow was measured with duplex ultrasound. There were 15 patients (34.1%) with a TAPSE of <16 mm. AVF blood flow was significantly higher in patients with impaired versus normal right ventricular function (1631.53 ± 738.17 vs. 1060.55 ± 539.92 min/ml, respectively, P = 0.003). Low left ventricular ejection fraction (odds ratio [OR]: 1.15, 95% confidence intervals [CI]: 1.007-1.334, P = 0.04), high interventricular septum thickness (OR: 1.64, 95% CI: 1.104-2.464, P = 0.01), and high AVF blood flow (OR: 1.00, 95% CI: 1.000-1.003, P = 0.03) were independent predictors of impaired right ventricular function. In addition to known risk factors that predominantly increase right ventricular afterload, excessive AVF blood flow was found to be independently associated with impaired right ventricular function, possibly by increasing right ventricular preload.
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Affiliation(s)
- S Yilmaz
- Department of Cardiovascular Surgery, Hitit University Faculty of Medicine, Corum Education and Research Hospital, Corum, Turkey
| | - M Yetim
- Department of Cardiology, Hitit University Faculty of Medicine, Corum Education and Research Hospital, Corum, Turkey
| | - B K Yilmaz
- Department of Radiology, Hitit University Faculty of Medicine, Corum Education and Research Hospital, Corum, Turkey
| | - T Dogan
- Department of Cardiology, Hitit University Faculty of Medicine, Corum Education and Research Hospital, Corum, Turkey
| | - E Aksoy
- Department of Cardiovascular Surgery, Hitit University Faculty of Medicine, Corum Education and Research Hospital, Corum, Turkey
| | - N Yuksel
- Department of Nursing, Hitit University Faculty of Medicine, Corum Education and Research Hospital, Corum, Turkey
| | - I Dogan
- Department of Nephrology, Hitit University Faculty of Medicine, Corum Education and Research Hospital, Corum, Turkey
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Balamuthusamy S, Jalandhara N, Subramanian A, Mohanaselvan A. Flow reduction in high-flow arteriovenous fistulas improve cardiovascular parameters and decreases need for hospitalization. Hemodial Int 2016; 20:362-8. [PMID: 26663664 DOI: 10.1111/hdi.12387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
High output heart failure (HF) and pulmonary hypertension have been demonstrated in patients with prevalent arteriovenous (AV) fistulas. Fistulas with flow >2000 mL/minutes are more likely to induce changes in cardiac geometry and pulmonary artery pressure. The effects of reducing flow in AV access and its implications on HF decompensation and hospitalizations have not been studied. Retrospective analysis of 12 patients who needed hospitalization for acute Congestive Heart Failure (CHF) decompensation with AV access flow of 2 L/minutes (as defined by Kidney Disease Outcomes Quality Initiative (KDOQI)) or more were included in the study. All the patients underwent banding of their inflow at the anastomosis with perioperative access flow measurement. Follow-up period was 6 months. 2D echo was done at 6 months postbanding in addition to access flow and clinical evaluation. Complete data was available for all the 12 patients. Study data was collected on all the 12 patients. Mean age was 64.7 years. The mean access flow pre and postbanding were 3784 mL/minutes and 1178 mL/minutes, respectively (P < 0.001). Eighty percent of the patients had diabetes and 41% had coronary artery disease. There was a statistically significant decrease in cardiac output (pre = 7.06 L/minutes, post = 6.47 L/minutes P = 0.03), pulmonary systolic pressure (pre = 54 mmHg, post = 44 mmHg P = 0.02), left ventricular mass index (LVMI) (pre = 130 g/m(2) , post = 125 g/m(2) P = 0.006) and need for rehospitalization for CHF decompensation. The New York Heart Association (NYHA) staging improved by 1 stage postbanding (P = 0.002). The hospitalization rate was 3.75 ± 1.2 in the 6 months before banding and was decreased to 1.08 ± 1.2 (P = 0.002) postbanding. The hemoglobin level, predialysis systolic blood pressure, calcium phosphorous product and the use of Renin Angiotensin Aldosterone System (RAAS) blockade agents and calcium channel blockers were comparable before and after inflow banding. Flow reduction in high flow fistulas are associated with decreased LVMI and pulmonary artery pressures. There is also a significant reduction in the risk for hospitalization due to acute HF and an improvement in NYHA heart failure stage.
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Affiliation(s)
- Saravanan Balamuthusamy
- Interventional Nephrology Division, Tarrant Vascular Access Center, Fort Worth, Texas, USA
- Interventional Nephrology Division, Tarrant Nephrology Associates, Fort Worth, Texas, USA
| | - Nishant Jalandhara
- Interventional Nephrology Division, Tarrant Vascular Access Center, Fort Worth, Texas, USA
- Interventional Nephrology Division, Tarrant Nephrology Associates, Fort Worth, Texas, USA
| | - Anand Subramanian
- Interventional Nephrology Division, Tarrant Nephrology Associates, Fort Worth, Texas, USA
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Agarwal AK. Systemic Effects of Hemodialysis Access. Adv Chronic Kidney Dis 2015; 22:459-65. [PMID: 26524951 DOI: 10.1053/j.ackd.2015.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 11/11/2022]
Abstract
Patients with advanced chronic kidney disease are at a high risk of cardiovascular events. Patients with end-stage renal disease have a particularly high morbidity and mortality, in part attributed to the complications and dysfunction related to vascular access in this population. Creation of an arteriovenous access for HD is considered standard of care for most patients and has distinct advantages including less likelihood of infections, less need for intervention, and positive impact on survival as compared with usage of a catheter. However, creation of an arteriovenous shunt incites a series of events that significantly impacts cardiovascular and neurohormonal health in both positive and negative ways. This article will review the short- and long-term effects of dialysis access on cardiovascular, neurohormonal, and pulmonary systems as well as a brief review of their effect on survival on HD. Presence of other comorbidities in a patient with dialysis access can amplify these effects, and these considerations are of paramount importance in individualizing the approach to not only the choice of vascular access but also the modality of kidney replacement therapy.
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