Arteriovenous fistula (AVF) is the best method of vascular access for hemodialysis. This approach can lead to several complications, such as hyperkinetic heart failure due to a hyperfunctional AVF or dilatation of the feeding artery. These are late complications, especially in patients after a successful kidney transplantation. An observational study was performed focusing on patients more than 12 months after kidney transplantation. The AVF was evaluated by ultrasound and, if the outflow exceeded 1.5 L/min, an echocardiogram was performed. Surgical management was indicated if the cardiac index was higher than 3.9 L/min/m2 or upon finding a brachial artery aneurysm. A total of 208 post- kidney transplantation patients were examined over a 3-year period, of which 46 subjects (22.11%) had hyperfunctional AVF and 34 cases (16.34%) of feeding artery dilatation were determined. In total, 40 AVF flow reduction and 6 AVF ligation procedures were performed. The median AVF flow before and after the reduction was 2955 mL/min and 1060 mL/min, respectively. Primary patency after flow reduction was 88.3% at 12 months. Late AVF complications in patients following kidney transplantation are quite common. It is necessary to create a screening program to monitor AVFs in these patients.
- MeSH
- Brachial Artery surgery MeSH
- Arteriovenous Shunt, Surgical * adverse effects MeSH
- Renal Dialysis * MeSH
- Adult MeSH
- Echocardiography MeSH
- Middle Aged MeSH
- Humans MeSH
- Follow-Up Studies MeSH
- Postoperative Complications etiology MeSH
- Vascular Patency MeSH
- Aged MeSH
- Kidney Transplantation * adverse effects MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Observational Study MeSH
Úvod: Nejčastější příčina úmrtí pacientů po transplantaci ledviny je kardiovaskulární onemocnění. Vysokoprůtočná arteriovenózní fistula (AVF) zvyšuje srdeční výdej a může se podílet na hyperkinetickém srdečním selhání. Sledování AVF u pacientů po transplantaci není zavedeno. Cílem naší práce bylo ve skupině pacientů po transplantaci ledviny s vysokoprůtočnou AVF provést redukci průtoku AVF ke snížení kardiálního zatížení. Metody: Byla provedena prospektivní studie u pacientů po transplantaci ledviny, kterým byl před transplantací založen cévní přístup k dialýze. AVF těchto pacientů byla vyšetřena ultrazvukem se zaměřením na průtok AVF a velikost arteria brachialis. V případě, že byla zjištěna vysokoprůtočná AVF, byla v indikované skupině pacientů provedena redukce průtoku. Výsledky: Bylo vyšetřeno 164 pacientů po transplantaci ledviny, z toho u 24 zjištěna hyperfunkční AVF. Celkem bylo provedeno 16 redukcí průtoku AVF, které vedly k průměrnému poklesu kardiálního indexu o 0,77 l/min/m2. Primární průchodnost rekonstrukcí byla 93,33 % po 12 měsících. U většiny pacientů došlo k subjektivnímu zmírnění dušnosti. Závěr: Redukce průtoku AVF vede ke zlepšení kvality života pacientů po transplantaci ledviny. Zachování funkční AVF je výhodné především u pacientů již opakovaně operovaných, kde jsou možnosti založení autologních AVF limitované.
Introduction: Cardiovascular disease is the most frequent cause of death in kidney transplant patients. High-flow arteriovenous fistula (AVF) increases cardiac output and may contribute to hyperkinetic heart failure. AVF follow-up is not implemented in kidney transplant patients. The aim of this study was to reduce AVF blood flow in a group of patients with a high-flow AVF following kidney transplantation to reduce cardiac strain. Methods: This prospective study was performed in kidney transplant patients who had a vascular access created before transplantation. The AVF of these patients was examined by ultrasound with a focus on AVF flow and brachial artery size. If high-flow AVF was detected, flow reduction was performed in the indicated group of patients. Results: The study examined 164 patients, of whom 24 had a hyperfunctional AVF (14.8%). A total of 16 AVF flow reductions were performed, which led to an average decrease in cardiac index by 0.77 L/min/m2. Primary patency of the reconstructions was 93.33% after 12 months. All patients experienced a subjective improvement in dyspnea. Conclusion: Reduction in AVF flow leads to an improvement in the quality of life of kidney transplant patients. Maintaining a functional AVF is beneficial, especially for patients after repeated surgeries, where the option of creating an autologous AVF is limited.
AIMS: Patients on chronic haemodialysis have a wide range of changes in cardiac function and structure, including left ventricular hypertrophy, dilation and diastolic dysfunction or pulmonary hypertension. All these changes were linked to increased mortality in previous studies. High-flow arteriovenous fistulas (AVF) are supposed to be a factor contributing to their development. This study investigated the early effect of surgical AVF blood flow (Qa) reduction on these changes in patients with or without heart failure changes. METHODS AND RESULTS: Forty-two patients in chronic haemodialysis programme with high-flow AVF (Qa over 1500 mL/min), indicated for surgery for ≥1 of the following indications: 1.manifest heart failure; 2.hand ischemia; 3.advanced structural heart changes detected by echocardiography. The patients underwent echocardiography on selection visit, before blood flow reducing surgery and six weeks thereafter. The Qa reduction led to decrease of left ventricular mass (p = 0.02), end-diastolic volume (p = 0.008), end-diastolic diameter (p = 0.003) and left atrial volume (p = 0.0006). Diastolic function improved. Similarly, right ventricular diameter and right atrial volume decreased (p = 0.000001 and 0.00009, respectively) together with the decrease of estimated pulmonary artery systolic pressure. 81% of patients suffered from pulmonary hypertension prior to surgery, only 36% thereafter. CONCLUSION: The surgical restriction of the hyperkinetic circulation leads to several improvements of heart structure and function, which was linked to higher mortality in other studies. The beneficial effect of Qa reduction is present even in patients without symptoms of heart failure. The contribution of AVF must be considered with structural or functional heart changes.
- MeSH
- Arteriovenous Shunt, Surgical * adverse effects MeSH
- Renal Dialysis adverse effects MeSH
- Echocardiography MeSH
- Hemodynamics MeSH
- Humans MeSH
- Heart Failure * diagnostic imaging therapy MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
BACKGROUND: Observation versus ligation of a functional arteriovenous fistula (AVF) after successful renal transplantation (SRT) has been a controversial topic of debate. Congestive heart failure and pulmonary hypertension are common in dialysis patients, and more frequent when vascular access flow is excessive. Renal transplant failure may occur in up to 34% of patients after 5 years, therefore maintaining a moderate flow AVF appears warranted. We review SRT patients with high flow-AVFs (HF-AVF) and clinical signs of heart failure where a modified precision banding procedure was used for access flow reduction. METHODS: Patients referred for HF-AVF evaluation after SRT were identified and records reviewed retrospectively. In addition to recording clinical signs of heart failure, each patient had ultrasound AVF flow measurement before and after temporary AVF occlusion of the access by digital compression. Pulse rate and the presence or absence of a cardiac murmur was noted before and after AVF compression. Adequacy of access flow restriction was evaluated intraoperatively using ultrasound flow measurements, adjusting the banding diameter in 0.5 mm increments to achieve the targeted AVF flow. RESULTS: Twelve patients were evaluated over a 19-month period. Eight (66%) were male and one (8%) obese. Ages were 15-73 years (mean = 42). The AVFs were established 24-86 months previously. The mean pulse rate declined after AVF compression from 90/min to 72/min (range 110-78). Six patients had a precompression cardiac flow murmur that disappeared with temporary AVF compression. One patient with poor cardiac function underwent immediate AVF ligation with dramatic improvement in cardiac status. All other patients underwent a precision banding procedure with real-time flow monitoring. Mean access flow was 2,280 mL/min (1,148-3,320 mL/min) before access banding and was 598 mL/min (481-876) after flow reduction. The clinical signs of heart failure disappeared in all patients. All AVFs remained patent although one individual later requested ligation for cosmesis. Two patients had renal transplant failure and later successfully used the AVF. Follow-up postbanding was 1-18 months (mean = 12). CONCLUSIONS: Patients with successful renal transplants and HF-AVFs had resolution of heart failure findings and maintenance of access patency using a modified precision banding procedure. Flow reduction in symptomatic renal transplant patients with elevated access flow is recommended. Further study is warranted to substantiate these recommendations and clarify the appropriate thresholds for such interventions.
- MeSH
- Arteriovenous Shunt, Surgical * adverse effects MeSH
- Time Factors MeSH
- Renal Dialysis * MeSH
- Adult MeSH
- Hemodynamics * MeSH
- Middle Aged MeSH
- Humans MeSH
- Ligation MeSH
- Adolescent MeSH
- Young Adult MeSH
- Kidney Diseases diagnosis surgery therapy MeSH
- Regional Blood Flow MeSH
- Reoperation MeSH
- Retrospective Studies MeSH
- Risk Factors MeSH
- Blood Flow Velocity MeSH
- Aged MeSH
- Heart Failure etiology physiopathology surgery MeSH
- Kidney Transplantation * adverse effects MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Adolescent MeSH
- Young Adult MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
OBJECTIVE: In 2008, a new technique of reinforced aneurysmorrhaphy with a polyester mesh tube for salvaging true aneurysmal arteriovenous (AV) haemodialysis access was described by us. In this study, the long-term patency and complication rates associated with this procedure were analysed, and the effect of reinforced aneurysmorrhaphy on high-flow vascular access was assessed. METHODS: This was a retrospective non-randomised study with prospectively collected data performed at a single centre. Patients with true aneurysmal haemodialysis AV access who underwent aneurysmorrhaphy with external mesh prosthesis between March 2007 and October 2012 were included. Clinical assessment and duplex ultrasound were performed preoperatively, 1, 3, and 12 months postoperatively, and annually thereafter. RESULTS: Data from 62 patients (median age 60 years, range 28-81 years; 63% men) were analysed. The commonest indication was high-flow vascular access associated with the risk of high output cardiac failure (24 patients, 39%). The mean follow-up time was 14.66 ± 12.80 months. Primary patency rates at 6 and 12 months were 86% and 79% respectively. Assisted primary patency rates at 6 and 12 months were 89% and 80% respectively. In 23 patients (96%) operated on for high-flow vascular access, decreased vascular access flow was observed after the procedure. The average flow reduction after aneurysmorrhaphy was 2,197 mL/minute. Postoperative bleeding and infection necessitating surgical revision occurred in three (4.8%) and three (4.8%) patients respectively. CONCLUSIONS: Reinforced aneurysmorrhaphy with an external mesh prosthesis is an effective method for treating true aneurysmal haemodialysis AV access, with excellent long-term patency and minimal complications due to infection.
- MeSH
- Aneurysm diagnosis surgery MeSH
- Blood Vessel Prosthesis Implantation methods MeSH
- Renal Dialysis methods MeSH
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Graft Occlusion, Vascular surgery MeSH
- Vascular Patency physiology MeSH
- Reoperation methods MeSH
- Retrospective Studies MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Vascular Surgical Procedures methods MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
Založení dialyzačního cévního zkratu má lokální i systémové hemodynamické důsledky. Pokles lokální cévní rezistence vede k urychlení krevního toku, a tím dochází ke zvýšení smykového napětí na cévní stěnu. To v konečném důsledku vede ke zvýšené produkci oxidu dusnatého, k dilataci přívodné tepny a ke zvýšení průtoku krve končetinou. Vysoký průtok může způsobit dekompenzaci chronického srdečního selhání, méně často hyperkinetické srdeční selhání. Nejčastější lokální komplikací je ischemie končetiny se zkratem. Životnost nativního zkratu i zkratu s PTFE protézou je omezena tvorbou stenóz, které snižují průtok a zvyšují riziko akutní trombózy a zániku zkratu. Pravidelný ultrasonografický screening umožňuje sledovat vývoj průtoku zkratem a kvantifikaci stenóz, což napomáhá ke správnému načasování cévní intervence. Komplexnost péče zajišťuje multioborová spolupráce na úrovni specializovaného centra, je snaha ji rozvíjet i na celorepublikové úrovni.
The creation of the dialysis vascular access has local and systemic hemodynamic effects. Decrease in the local vascular resistance leads to the acceleration of blood flow, which increases vascular wall shear stress. This ultimately leads to increased production of nitric oxide, dilatation of the feeding artery and increase of blood flow to the limb. High blood flow can cause decompensation of chronic congestive heart failure, less often hyperkinetic heart failure. The most common local complication is ischemia of the limb with the access. The lifespan of native fistulas and accesses with PTFE grafts is limited by the development of stenosis, which leads to the reduction in flow and increases the risk of acute thrombosis and access failure. Regular ultrasonographic screening allows an adequate monitoring of the access flow and quantification of stenoses, which helps to time the vascular intervention. The complexity of care is provided by a multidisciplinary team in specialized centre; we make efforts to develop this cooperation on a national level.
- Keywords
- dialyzační cévní zkrat, lokální a systémová hemodynamika, ultrasonografický screening,
- MeSH
- Arteriovenous Shunt, Surgical methods adverse effects utilization MeSH
- Vascular Malformations surgery prevention & control MeSH
- Renal Dialysis methods adverse effects utilization MeSH
- Hemodynamics MeSH
- Ischemia MeSH
- Extremities physiopathology MeSH
- Humans MeSH
- Interdisciplinary Communication MeSH
- Hypertension, Renal etiology prevention & control MeSH
- Risk Factors MeSH
- Blood Flow Velocity MeSH
- Heart Failure MeSH
- Ultrasonography methods utilization MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
AIM: To assess the variability of blood flow (QVA) through a native arteriovenous fistula (AVF) in the long-term and to determine the QVA reduction at which an intervention is appropriate.
