ASDIN Original Investigations: Inflow Reduction by Distalization of Anastomosis Treats Efficiently High‐Inflow High‐Cardiac Output Vascular Access for Hemodialysis

Abstract

The arteriovenous fistula used for vascular access for hemodialysis may contribute to development of congestive heart failure. Theses patients can present with frequent episodes of congestive hear failure. Traditional management of high-inflow, a high-cardiac-output fistula generally involves either closure or banding. Although high-output state can be controlled, the lifeline of the patient is lost. We describe a series of 17 hemodialysis patients (10 men and 7 women) in whom a novel inflow reduction method was employed. All patients had symptoms of heart failure (15 brachiocephalic fistulas and two brachioaxillary bypass grafts) and a fistula inflow rate above 1600 ml/min. The inflow reduction procedure included ligation of the brachial anastomosis and reconstruction of the fistula by using an expanded polytetrafluoroethylene (Gore-Tex Intering) vascular graft in a bypass from the radial artery. The mean (+/- SD) time between fistula creation and the inflow reduction procedure was 30 +/- 17 months. The mean access inflow rate decreased significantly after the inflow reduction procedure, from 3135 +/- 692 to 1025 +/- 551 ml/min (p =0.0001). The mean cardiac output rate decreased from 8 +/- 3.1 to 5.6 +/- 1.7 l/min (p = 0.001) with resolution of symptoms. During the follow-up period thrombosis or stenosis developed in seven patients, three of whom underwent surgical revision. Thirteen of the seventeen accesses (77%) subjected to the inflow reduction procedure remained patent. Access loss was due to failed fistuloplasty or thrombosis. To our knowledge, this is the first report demonstrating that inflow reduction obtained by distalization of the anastomosis of the access fistula is feasible and safe for managing high-inflow, high-cardiac-output fistulas. Longer and larger studies of the inflow reduction procedure and its benefits are needed.

Impact of inflow reduction of arteriovenous fistula on systemic hemodynamics in a patient with high-output heart failure during hemodialysis: A case report

“…High-output heart failure is a rare complication of arteriovenous fistulas (AVF) for hemodialysis [1][2][3][4][5]. Although closure or flow reduction of AVF has been known to improve highoutput status [1][2][3][4], few data exist regarding the impact of these procedures on systemic hemodynamics.…”

Local Hemodynamics of the Vascular Access for Hemodialysis

“…Unfortunately, it is difficult to perform a longer study with the exclusion of potential confounding variables (such as comorbidities, progression of kidney failure), because such variables also change over time. Chemla et al [47] documented relief of heart failure symptoms and decrease in cardiac output after surgical high-access flow reduction. Interestingly, it seems that the necessary increase in cardiac output to sustain the high-access flow must be numerically greater than the actual access flow [48] .…”

Creation of dialysis vascular access with normal flow increases brain natriuretic peptide levels

“…It is also an argument for routine access flow monitoring, which is still not provided in all hemodialysis centers. Fortunately, hyperkinetic heart failure seems to be reversible, if treated without delay [22]. Another question is if the increase of BNP levels after access creation persists for a long time or if it is only a temporary disequilibrium as suspected from our study (6-month results).…”