An increasing number of renal dialysis-dependent patients with Arterio-Venous fistulae are undergoing cardiac surgery.The fistula has important effects on systemic hemodynamics in dialysis patients. The flow is significantly and positively related to cardiac output and cardiac index, and inversely related to pulmonary vascular resistance.Few problems are encountered on cardiopulmonary bypass despite left to right shunting of blood. We present an unusual case in which a large brachial Arterio-Venous fistula with large collaterals prevented weaning off cardiopulmonary bypass.

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