Maturation of Arteriovenous Fistulas in Patients with Ventricular Assist Devices
Karim M. Salem, MD, Adham N. Abou Ali, MD, Raymond E. Eid, MD, Rabih A. Chaer, MD, Robert L. Kormos, MD, Efthymios D. Avgerinos, MD.
UPMC, Pittsburgh, PA, USA.
Objective: Postoperative renal dysfunction necessitating long-term hemodialysis after implantation of Ventricular Assist Devices (VADs) presents a challenge with respect to establishment of dialysis access. Use of catheters in this population places them at increased risk of bloodstream and thus VAD infection. Lack of pulsatile flow has led to concerns that arteriovenous fistulas (AVFs) will not mature. This study aims to evaluate AVF as a method of dialysis access.
Methods: Consecutive patients who underwent implantation of a VAD between 1988 and 2016 with a subsequent need for hemodialysis were identified. Retrospective data was collected for patients requiring hemodialysis through an AVF or an arteriovenous graft (AVG) as their means of access. We report on fistula flow rates and the duration of dialysis.
Results: 64 patients were identified (58 received hemodialysis via tunneled dialysis catheters (TDC), 5 via an AVF and 1 via an AVG). 3/6 patients underwent VAD placement as destination therapy. All 6 patients were on continuous-flow VADs. Their mean age was 62.2±10.0 years, and all were males. Brachiocephalic AVFs were performed in all 5 AVF patients, and the average preoperative vein diameter was 4.1 ± 0.9 mm. On 30-day follow up, the average flow rate was 1262±643 ml/min (range 880-2220). Of the 5 patients, 1 died at 30 days, 1 AVF required ligation for steal syndrome at 5 months, and 1 was abandoned after 325 days for low flow. Of the 2 remaining fistulas 1 thrombosed at 630 days and was converted to an AVG which has been patent for 168 days, and 1 remains open at 784 days.
Conclusion: Arteriovenous fistulas should be considered in selected patients with VADs as a means of long-term hemodialysis access to avoid use of dialysis catheters. Maturation and usage of primary AVFs is possible despite lack of pulsatile flow.
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