- Email: [email protected]
Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula Causing High Cardiac Output Heart Failure
Journal Pre-proof Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula Causing High Cardiac Output Heart Failure Anthony D. Turner, MD, MBA, Michael Chen, MD, Neera Dahl, MD, Leslie Scoutt, MD, Alan Dardik, MD, PhD, Cassius Iyad Ochoa Chaar, MD, MS PII:
S0890-5096(19)31052-0
DOI:
https://doi.org/10.1016/j.avsg.2019.12.011
Reference:
AVSG 4821
To appear in:
Annals of Vascular Surgery
Received Date: 27 April 2019 Revised Date:
4 November 2019
Accepted Date: 6 December 2019
Please cite this article as: Turner AD, Chen M, Dahl N, Scoutt L, Dardik A, Ochoa Chaar CI, Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula Causing High Cardiac Output Heart Failure, Annals of Vascular Surgery (2020), doi: https://doi.org/10.1016/ j.avsg.2019.12.011. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
1
Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula
2
Causing High Cardiac Output Heart Failure
3 4
Anthony D. Turner, MD, MBA1, Michael Chen, MD2, Neera Dahl, MD3, Leslie Scoutt,
5
MD4, Alan Dardik, MD, PhD1, Cassius Iyad Ochoa Chaar, MD, MS1
6 7 8 9 10 11 12 13 14 15 16
1
Department of Surgery, Division of Vascular Surgery Yale School of Medicine 333 Cedar Street, Boardman 204 PO Box 208062 New Haven, CT 06520-8039 United States of America Telephone: 203-785-2561 Fax: 203-785-7556 Email: [email protected]
2
17 18 19 20 21 22 23
Department of Internal Medicine, section of Cardiology, Yale School of Medicine, New Haven, CT, United States of America 3 Department of Internal Medicine, section of Nephrology, Yale School of Medicine, New Haven, CT, United States of America 4 Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America
24
Corresponding Author: Anthony D. Turner, MD, MBA: [email protected]
25
Michael Chen, MD: [email protected]
26
Neera Dahl, MD: [email protected]
27
Leslie Scoutt, MD: [email protected]
28
Alan Dardik, MD, PhD: [email protected]
29
Cassius Iyad Ochoa Chaar, MD, MS: [email protected]
30
*All figures printed in color.
31
Turner et al., 2 32
Abstract
33
The creation of an arteriovenous fistula (AVF) is the preferred mode of access for
34
hemodialysis in patients with End-Stage Renal Disease (ESRD). High output cardiac failure is a
35
known but rare complication of AVF resulting from high flow volume. This case report
36
describes the use of intraoperative ultrasound as a guide for banding of an AVF to decrease flow
37
volume in a patient with high cardiac output failure. The access was preserved and a gradual
38
decline of cardiac function before and recovery after banding is demonstrated over an 18-year
39
period.
40
Introduction
41
High output cardiac failure is a rare complication of high-flow arteriovenous fistula
42
(AVF). This is defined as symptoms of exertional dyspnea, orthopnea, and peripheral edema in
43
the presence of an elevated cardiac index (>3.0 L/min/m2)1. The rate of AVF banding or ligation
44
due to worsening congestive heart failure (CHF) was identified as 2.6% in a cohort of 204
45
patients (322 accesses), according to a study by Dixon et al2. The mean time between initial
46
fistula creation and discovery of high cardiac output failure was 30 ± 17 months (range, 6-53)3.
47
Guidelines for ranges of blood flow within a typical dialysis access are as follows: low (600
48
mL/min), normal (600-1500 mL/min), and high (>1500 mL/min) categories4. We present a case
49
in which intraoperative ultrasound of an AVF was utilized as a guide for banding with
50
subsequent confirmed reduction in flow rate. The patient was successfully treated and
51
experienced remarkable improvement in heart failure symptoms. The patient consented to
52
publication of this case report.
53
Case Presentation
Turner et al., 3 54
A 53-year-old obese (BMI =31.6 kg/m2) woman with past medical history of ESRD
55
secondary to focal segmental glomerulosclerosis on hemodialysis for 15 years, renal cell
56
carcinoma, atrial fibrillation, and non-ischemic cardiomyopathy with biventricular failure
57
presented for evaluation of aneurysmal arteriovenous hemodialysis access. Her surgical history
58
was significant for a right brachiocephalic AVF creation in 2001 that provided uninterrupted
59
hemodialysis access without complication for 14 years. She complained of increasing dyspnea
60
on exertion (DOE) consistent with New York Heart Association (NYHA) Class III symptoms,
61
requiring two hospital admissions over a period of 2 years. Her EKG showed atrial fibrillation
62
with a heart rate of 90 beats per minute (bpm) and her echocardiogram demonstrated a reduced
63
ejection fraction (EF) of 35%. Figure 1 demonstrates the gradual decrease in EF over time from
64
60% in year 2000 (Figure I).
65
Left heart catherization demonstrated normal coronary arteries. Right heart catherization
66
revealed an elevated cardiac output (CO) and cardiac index (CI) at 11.2 L/min and 4.8 L/min/m2,
67
respectively. Systemic vascular resistance was remarkably low at 277 dynes/sec/cm-5 (normal:
68
700-1,500 dynes/sec/cm-5) which is consistent with high output heart failure. Chest radiograph
69
demonstrated cardiomegaly. On exam, the AVF had a small superficial eschar and 3 areas of
70
aneurysmal degeneration. A strong thrill was present without frank ulceration. Ultrasound of the
71
access showed no stenosis and a markedly elevated flow volume of 5 L/min proximal to the
72
anastomosis.
73
The surgical plan was to perform open revision of the largest aneurysm first with
74
imbrication or banding to decrease the flow and then tackle the 2 remaining aneurysms at a later
75
stage to avoid interruption in dialysis through the access necessitating placement of a dialysis
76
catheter. In late 2014, the patient underwent the first stage of surgery for open revision of her
Turner et al., 4 77
right brachiocephalic AVF with resection of the largest aneurysm and banding of the fistula.
78
After dissecting the aneurysm and heparinization, the AVF was controlled with vessel loops and
79
the aneurysm was opened and the excess wall was resected. Intraoperative ultrasound was used
80
to assess the flow rate (Figure II). Then, the remaining aneurysm wall was plicated with 5-0
81
running Prolene sutures over 16-French sheath to prevent stenosis and create a diameter of 5 mm
82
(Figure III). The flow rate as calculated by the intraoperative Doppler ultrasound decreased to 3
83
L/min but was still relatively high. Our goal was to achieve an access flow rate of 1 L/min. Next,
84
a 0.8 x 0.8cm bovine pericardial patch was used to band the revised portion of the AVF which
85
reduced the flow rate to 1.2 L/min (Figure IV). We divided a longitudinal short strip of the patch
86
and closed it on the vein with 3-0 prolene interrupted sutures. The patient had an uneventful
87
postoperative course and uninterrupted use of the AVF remained possible through the other non-
88
aneurysmal portions.
89
A month later, the remaining aneurysms were revised and that allowed her to avoid
90
placement of a dialysis catheter. The DOE improved with symptoms consistent with NYHA
91
Class II. The EF increased to 52% over 2 years, while left ventricular diastolic dimension
92
(LVDD) decreased from 5.7 cm to 4.8 cm. Repeat Doppler ultrasound at 2 years demonstrated a
93
fistula flow volume of 2.1 L/min, substantially decreased from the original 5 L/min on
94
presentation. No stenosis or other abnormalities were observed. Her cardiac index, measured
95
with non-invasive echocardiogram, increased from 1.9 L/min/m2 to 4 L/min/m2. This trend in
96
cardiac index was corrected after a decrease from 4.8 L/min/m2 in 2012. Ultimately, the patient
97
experienced an inverse relationship between her systemic vascular resistance and cardiac index
98
(Figure V). She remained stable for more than 2 years without hospital admissions for heart
99
failure and continues to use the access for dialysis.
Turner et al., 5 100
Discussion
101
This case report highlights the detrimental effects of high flow AVF on cardiac function
102
with successful reversal after banding and revision of the access over a period of 18 years. High
103
output cardiac failure caused by a high-flow AVF can manifest as systemic venous or pulmonary
104
congestion and a resting cardiac output greater than 8 L/min5. Clinical findings may include
105
prolonged bleeding, arm swelling, jugular venous distention (JVD), coarse lung crackles, S3
106
heart sound, and bilateral leg edema. When suspected, diagnostic evaluation often involves chest
107
radiograph, echocardiogram, and right heart catheterization6. Worsening cardiac function after
108
AVF creation can be a result of shunting of blood flow from the high resistance arterial system
109
into the low resistance venous system, with subsequent increase in venous return and CO.
110
Studies evaluating echocardiographic changes after AVF creation demonstrated an increase in
111
left ventricular end-diastolic volume (LVEDV), contractility, stroke volume and CO within 7–10
112
days after surgery. On average, the creation of an AVF increases CO by 15–20% and left
113
ventricular end-diastolic pressure by 5–10%7. If untreated, cardiac decompensation will progress
114
resulting in a precipitous decrease in cardiac index with reciprocal elevation in systemic vascular
115
resistance.
116
Treatment of high-output heart failure secondary to excess arteriovenous shunting
117
involves flow reduction procedures including surgical banding or ligation1. Surveillance
118
measures such as duplex Doppler ultrasound is commonly used to measure blood flow before
119
and after surgery8. Our literature analysis has identified cases of intraoperative flow monitoring
120
for banding of high output AVFs using modified Swan Ganz catheters or ultrasound guided
121
banding of an AVF before and after the procedure. A suture tied externally over a 10-French
122
dilator for high-flow AVF banding was used by Letachowicz et al. with ultrasound performed
Turner et al., 6 123
before and after surgery. The authors performed surgical banding on 12 patients who all showed
124
cardiac hypertrophy on echocardiography but only four patients with signs of heart failure using
125
external dilator-assisted banding instead of endovascular catheterization. The study reported that
126
mean brachial blood flows were 3733.2 ± 826.2 mL/min preoperatively and
127
1461.2 ± 337.7 mL/min after surgery for a mean flow reduction of 2272.2 ± 726.9 mL/min9.
128
A study by Gkotsis et al. utilized intraoperative ultrasound for precision fistula banding
129
after a successful renal transplant. Even after kidney transplantation with suboptimal impaired
130
graft function most physicians prefer AVF blood flow reduction as a safer option rather than
131
fistula ligation10. However, surgical banding carries an 11% risk of thrombosis and a 2.8%
132
infection risk in the early postoperative period. The risks of AVF thrombosis is higher with
133
greater reduction of flow2. This served as our impetus for using intraoperative Doppler
134
ultrasound and closing over a 16-French sheath in order to mitigate the risk of extensive
135
narrowing and thrombosis of the access, as opposed to suture tying externally over a 10-French
136
dilator. Following the procedure, the patient experienced a marked decrease in systemic vascular
137
resistance from 1,558 dynes/sec/cm5 preoperatively to 590.9 dynes/sec/cm5 over 3 years.
138
Similarly, interval improvement in her previously diminished cardiac index increased from 1.9
139
L/min/m2 to 4L/min/m2 over 3 years.
140
The method of intraoperative ultrasound was utilized in our case report to accurately
141
band an AVF to a specific size. We did an open revision of an access and used a sheath to gauge
142
the caliber of the imbrication which decreased the flow compared to baseline. However, the AVF
143
still maintained high-flow rates which required subsequent banding. Intraoperative Doppler
144
ultrasound was a paramount resource to gauge our technique and ensure precise results.
145
Conclusion
Turner et al., 7 146
Arteriovenous fistulas are crucial for long-term hemodialysis in patients with ESRD.
147
Rarely, this is complicated by high output cardiac failure which is amenable to surgical banding.
148
Intraoperative duplex Doppler ultrasound is a useful adjunct to assess flow volume and guide
149
banding of hemodialysis access. Reduction of flow volume can lead to sustained recovery of
150
cardiac function.
151 152 153
References
154
Fistulas. Journal of Cardiology Cases. 2015 May; 11(5): 132-135.
155
[2] Dixon, B.S., Novak, L., Fangman, J. Hemodialysis Vascular Access Survival: Upper-Arm
156
Native Arteriovenous Fistula. American Journal of Kidney Diseases. 2002 January; 39(1): 92-
157
101.
158
[3] Chemla, E.S., Morsy, M., Anderson, L. et al, Inflow Reduction by Distalization of
159
Anastomosis Treats Efficiently High-Inflow High-Cardiac Output Vascular Access for
160
Hemodialysis. Seminars in Dialysis. 2007 January-February; 20(1): 68-72.
161
[4] Miller, G.A., Hwang, W.W. Challenges and Management of High-Flow Arteriovenous
162
Fistula. Seminars in Nephrology. 2012 November; 32(6): 545-550.
163
[5] Tordoir, J., Canaud, B., Haage, P. et al, Evidence-Based Practice Guidelines on Vascular
164
Access. Nephrology Dialysis Transplant. 2007 May; 22(2): ii88-ii117.
165
[6] Zamboli, P., Luca, S., Borrelli, S. et al, High-Flow Arteriovenous Fistula and Heart
166
Failure: Could the Indexation of Blood Flow Rate and Echocardiography Have a Role in
167
the Identification of Patients at Higher Risk? Journal of Nephrology. 2018 December; 31(6):
168
975-983.
[1] Imran, T.F., Hashim, H., Beidas, A.K. et al, A Covert Complication of Arteriovenous
Turner et al., 8 169
[7] Agarwal, A.K. Systemic Effects of Hemodialysis Access. Advances in Chronic Kidney
170
Disease. 2015 November; 22(6): 459-465.
171
[8] Quencer, K.B., Kidd, J., Kinney, T. Preprocedure Evaluation of a Dysfunctional Dialysis
172
Access. Techniques in Vascular and Interventional Radiology. 2017 March; 20(1): 20-30.
173
[9] Letachowicz, K., Kusztal, M., Golebiowski, T. et al, External Dilator-Assisted Banding
174
for High-Flow Hemodialysis Arteriovenous Fistula. Renal Failure. 2016 January; 38(7):
175
1067-1070.
176
[10] Gkotsis, G., Jennings, W.C., Malik, J. et al, Treatment of High Flow Arteriovenous
177
Fistulas after Successful Renal Transplant Using a Simple Precision Banding Technique.
178
Annals of Vascular Surgery. 2016 February; 31: 85-92019.
S0890-5096(19)31052-0
DOI:
https://doi.org/10.1016/j.avsg.2019.12.011
Reference:
AVSG 4821
To appear in:
Annals of Vascular Surgery
Received Date: 27 April 2019 Revised Date:
4 November 2019
Accepted Date: 6 December 2019
Please cite this article as: Turner AD, Chen M, Dahl N, Scoutt L, Dardik A, Ochoa Chaar CI, Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula Causing High Cardiac Output Heart Failure, Annals of Vascular Surgery (2020), doi: https://doi.org/10.1016/ j.avsg.2019.12.011. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
1
Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula
2
Causing High Cardiac Output Heart Failure
3 4
Anthony D. Turner, MD, MBA1, Michael Chen, MD2, Neera Dahl, MD3, Leslie Scoutt,
5
MD4, Alan Dardik, MD, PhD1, Cassius Iyad Ochoa Chaar, MD, MS1
6 7 8 9 10 11 12 13 14 15 16
1
Department of Surgery, Division of Vascular Surgery Yale School of Medicine 333 Cedar Street, Boardman 204 PO Box 208062 New Haven, CT 06520-8039 United States of America Telephone: 203-785-2561 Fax: 203-785-7556 Email: [email protected]
2
17 18 19 20 21 22 23
Department of Internal Medicine, section of Cardiology, Yale School of Medicine, New Haven, CT, United States of America 3 Department of Internal Medicine, section of Nephrology, Yale School of Medicine, New Haven, CT, United States of America 4 Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America
24
Corresponding Author: Anthony D. Turner, MD, MBA: [email protected]
25
Michael Chen, MD: [email protected]
26
Neera Dahl, MD: [email protected]
27
Leslie Scoutt, MD: [email protected]
28
Alan Dardik, MD, PhD: [email protected]
29
Cassius Iyad Ochoa Chaar, MD, MS: [email protected]
30
*All figures printed in color.
31
Turner et al., 2 32
Abstract
33
The creation of an arteriovenous fistula (AVF) is the preferred mode of access for
34
hemodialysis in patients with End-Stage Renal Disease (ESRD). High output cardiac failure is a
35
known but rare complication of AVF resulting from high flow volume. This case report
36
describes the use of intraoperative ultrasound as a guide for banding of an AVF to decrease flow
37
volume in a patient with high cardiac output failure. The access was preserved and a gradual
38
decline of cardiac function before and recovery after banding is demonstrated over an 18-year
39
period.
40
Introduction
41
High output cardiac failure is a rare complication of high-flow arteriovenous fistula
42
(AVF). This is defined as symptoms of exertional dyspnea, orthopnea, and peripheral edema in
43
the presence of an elevated cardiac index (>3.0 L/min/m2)1. The rate of AVF banding or ligation
44
due to worsening congestive heart failure (CHF) was identified as 2.6% in a cohort of 204
45
patients (322 accesses), according to a study by Dixon et al2. The mean time between initial
46
fistula creation and discovery of high cardiac output failure was 30 ± 17 months (range, 6-53)3.
47
Guidelines for ranges of blood flow within a typical dialysis access are as follows: low (600
48
mL/min), normal (600-1500 mL/min), and high (>1500 mL/min) categories4. We present a case
49
in which intraoperative ultrasound of an AVF was utilized as a guide for banding with
50
subsequent confirmed reduction in flow rate. The patient was successfully treated and
51
experienced remarkable improvement in heart failure symptoms. The patient consented to
52
publication of this case report.
53
Case Presentation
Turner et al., 3 54
A 53-year-old obese (BMI =31.6 kg/m2) woman with past medical history of ESRD
55
secondary to focal segmental glomerulosclerosis on hemodialysis for 15 years, renal cell
56
carcinoma, atrial fibrillation, and non-ischemic cardiomyopathy with biventricular failure
57
presented for evaluation of aneurysmal arteriovenous hemodialysis access. Her surgical history
58
was significant for a right brachiocephalic AVF creation in 2001 that provided uninterrupted
59
hemodialysis access without complication for 14 years. She complained of increasing dyspnea
60
on exertion (DOE) consistent with New York Heart Association (NYHA) Class III symptoms,
61
requiring two hospital admissions over a period of 2 years. Her EKG showed atrial fibrillation
62
with a heart rate of 90 beats per minute (bpm) and her echocardiogram demonstrated a reduced
63
ejection fraction (EF) of 35%. Figure 1 demonstrates the gradual decrease in EF over time from
64
60% in year 2000 (Figure I).
65
Left heart catherization demonstrated normal coronary arteries. Right heart catherization
66
revealed an elevated cardiac output (CO) and cardiac index (CI) at 11.2 L/min and 4.8 L/min/m2,
67
respectively. Systemic vascular resistance was remarkably low at 277 dynes/sec/cm-5 (normal:
68
700-1,500 dynes/sec/cm-5) which is consistent with high output heart failure. Chest radiograph
69
demonstrated cardiomegaly. On exam, the AVF had a small superficial eschar and 3 areas of
70
aneurysmal degeneration. A strong thrill was present without frank ulceration. Ultrasound of the
71
access showed no stenosis and a markedly elevated flow volume of 5 L/min proximal to the
72
anastomosis.
73
The surgical plan was to perform open revision of the largest aneurysm first with
74
imbrication or banding to decrease the flow and then tackle the 2 remaining aneurysms at a later
75
stage to avoid interruption in dialysis through the access necessitating placement of a dialysis
76
catheter. In late 2014, the patient underwent the first stage of surgery for open revision of her
Turner et al., 4 77
right brachiocephalic AVF with resection of the largest aneurysm and banding of the fistula.
78
After dissecting the aneurysm and heparinization, the AVF was controlled with vessel loops and
79
the aneurysm was opened and the excess wall was resected. Intraoperative ultrasound was used
80
to assess the flow rate (Figure II). Then, the remaining aneurysm wall was plicated with 5-0
81
running Prolene sutures over 16-French sheath to prevent stenosis and create a diameter of 5 mm
82
(Figure III). The flow rate as calculated by the intraoperative Doppler ultrasound decreased to 3
83
L/min but was still relatively high. Our goal was to achieve an access flow rate of 1 L/min. Next,
84
a 0.8 x 0.8cm bovine pericardial patch was used to band the revised portion of the AVF which
85
reduced the flow rate to 1.2 L/min (Figure IV). We divided a longitudinal short strip of the patch
86
and closed it on the vein with 3-0 prolene interrupted sutures. The patient had an uneventful
87
postoperative course and uninterrupted use of the AVF remained possible through the other non-
88
aneurysmal portions.
89
A month later, the remaining aneurysms were revised and that allowed her to avoid
90
placement of a dialysis catheter. The DOE improved with symptoms consistent with NYHA
91
Class II. The EF increased to 52% over 2 years, while left ventricular diastolic dimension
92
(LVDD) decreased from 5.7 cm to 4.8 cm. Repeat Doppler ultrasound at 2 years demonstrated a
93
fistula flow volume of 2.1 L/min, substantially decreased from the original 5 L/min on
94
presentation. No stenosis or other abnormalities were observed. Her cardiac index, measured
95
with non-invasive echocardiogram, increased from 1.9 L/min/m2 to 4 L/min/m2. This trend in
96
cardiac index was corrected after a decrease from 4.8 L/min/m2 in 2012. Ultimately, the patient
97
experienced an inverse relationship between her systemic vascular resistance and cardiac index
98
(Figure V). She remained stable for more than 2 years without hospital admissions for heart
99
failure and continues to use the access for dialysis.
Turner et al., 5 100
Discussion
101
This case report highlights the detrimental effects of high flow AVF on cardiac function
102
with successful reversal after banding and revision of the access over a period of 18 years. High
103
output cardiac failure caused by a high-flow AVF can manifest as systemic venous or pulmonary
104
congestion and a resting cardiac output greater than 8 L/min5. Clinical findings may include
105
prolonged bleeding, arm swelling, jugular venous distention (JVD), coarse lung crackles, S3
106
heart sound, and bilateral leg edema. When suspected, diagnostic evaluation often involves chest
107
radiograph, echocardiogram, and right heart catheterization6. Worsening cardiac function after
108
AVF creation can be a result of shunting of blood flow from the high resistance arterial system
109
into the low resistance venous system, with subsequent increase in venous return and CO.
110
Studies evaluating echocardiographic changes after AVF creation demonstrated an increase in
111
left ventricular end-diastolic volume (LVEDV), contractility, stroke volume and CO within 7–10
112
days after surgery. On average, the creation of an AVF increases CO by 15–20% and left
113
ventricular end-diastolic pressure by 5–10%7. If untreated, cardiac decompensation will progress
114
resulting in a precipitous decrease in cardiac index with reciprocal elevation in systemic vascular
115
resistance.
116
Treatment of high-output heart failure secondary to excess arteriovenous shunting
117
involves flow reduction procedures including surgical banding or ligation1. Surveillance
118
measures such as duplex Doppler ultrasound is commonly used to measure blood flow before
119
and after surgery8. Our literature analysis has identified cases of intraoperative flow monitoring
120
for banding of high output AVFs using modified Swan Ganz catheters or ultrasound guided
121
banding of an AVF before and after the procedure. A suture tied externally over a 10-French
122
dilator for high-flow AVF banding was used by Letachowicz et al. with ultrasound performed
Turner et al., 6 123
before and after surgery. The authors performed surgical banding on 12 patients who all showed
124
cardiac hypertrophy on echocardiography but only four patients with signs of heart failure using
125
external dilator-assisted banding instead of endovascular catheterization. The study reported that
126
mean brachial blood flows were 3733.2 ± 826.2 mL/min preoperatively and
127
1461.2 ± 337.7 mL/min after surgery for a mean flow reduction of 2272.2 ± 726.9 mL/min9.
128
A study by Gkotsis et al. utilized intraoperative ultrasound for precision fistula banding
129
after a successful renal transplant. Even after kidney transplantation with suboptimal impaired
130
graft function most physicians prefer AVF blood flow reduction as a safer option rather than
131
fistula ligation10. However, surgical banding carries an 11% risk of thrombosis and a 2.8%
132
infection risk in the early postoperative period. The risks of AVF thrombosis is higher with
133
greater reduction of flow2. This served as our impetus for using intraoperative Doppler
134
ultrasound and closing over a 16-French sheath in order to mitigate the risk of extensive
135
narrowing and thrombosis of the access, as opposed to suture tying externally over a 10-French
136
dilator. Following the procedure, the patient experienced a marked decrease in systemic vascular
137
resistance from 1,558 dynes/sec/cm5 preoperatively to 590.9 dynes/sec/cm5 over 3 years.
138
Similarly, interval improvement in her previously diminished cardiac index increased from 1.9
139
L/min/m2 to 4L/min/m2 over 3 years.
140
The method of intraoperative ultrasound was utilized in our case report to accurately
141
band an AVF to a specific size. We did an open revision of an access and used a sheath to gauge
142
the caliber of the imbrication which decreased the flow compared to baseline. However, the AVF
143
still maintained high-flow rates which required subsequent banding. Intraoperative Doppler
144
ultrasound was a paramount resource to gauge our technique and ensure precise results.
145
Conclusion
Turner et al., 7 146
Arteriovenous fistulas are crucial for long-term hemodialysis in patients with ESRD.
147
Rarely, this is complicated by high output cardiac failure which is amenable to surgical banding.
148
Intraoperative duplex Doppler ultrasound is a useful adjunct to assess flow volume and guide
149
banding of hemodialysis access. Reduction of flow volume can lead to sustained recovery of
150
cardiac function.
151 152 153
References
154
Fistulas. Journal of Cardiology Cases. 2015 May; 11(5): 132-135.
155
[2] Dixon, B.S., Novak, L., Fangman, J. Hemodialysis Vascular Access Survival: Upper-Arm
156
Native Arteriovenous Fistula. American Journal of Kidney Diseases. 2002 January; 39(1): 92-
157
101.
158
[3] Chemla, E.S., Morsy, M., Anderson, L. et al, Inflow Reduction by Distalization of
159
Anastomosis Treats Efficiently High-Inflow High-Cardiac Output Vascular Access for
160
Hemodialysis. Seminars in Dialysis. 2007 January-February; 20(1): 68-72.
161
[4] Miller, G.A., Hwang, W.W. Challenges and Management of High-Flow Arteriovenous
162
Fistula. Seminars in Nephrology. 2012 November; 32(6): 545-550.
163
[5] Tordoir, J., Canaud, B., Haage, P. et al, Evidence-Based Practice Guidelines on Vascular
164
Access. Nephrology Dialysis Transplant. 2007 May; 22(2): ii88-ii117.
165
[6] Zamboli, P., Luca, S., Borrelli, S. et al, High-Flow Arteriovenous Fistula and Heart
166
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