Impact of Preexisting Structural Cardiac Disease on Successful Arteriovenous Access Creation
Jeffrey B Edwards, Zachary B Fang, Susan M Shafii, Luke P Brewster, Arya Shipra, Yazan Duwayri, Ravi K Veeraswamy, Thomas F Dodson, Ravi R Rajani
Emory University School of Medicine, Atlanta, GA
Background: Permanent arteriovenous access has been widely accepted as the preferred modality of vascular access in hemodialysis for its reduced morbidity and mortality compared with other options. Current guidelines recommend that hemodialysis should be initiated via permanent access, but fistula or graft maturation is a challenge in some patient populations. A preoperative diagnosis of heart failure has been implicated as one potential contributor to access non-maturation, but the effect of specific parameters of cardiac function have not been previously studied.
Methods: Retrospective chart review was performed for all patients who underwent permanent arteriovenous access creation at a single institution over a three year period. Data collected included standard demographics, preoperative echocardiogram data (ejection fraction [EF], presence of diastolic dysfunction, and presence of greater than mild valvular disease), access creation, and follow-up data. Maturation was defined as the ability to be successfully dialyzed via permanent access. Outcomes were compared with respect to ejection fraction, presence of diastolic dysfunction, and valvular disease.
Results: 45 patients were identified with a preoperative echocardiogram prior to access creation. 22 (47%) had an EF ≤50%, 31 (69%) had preoperative diastolic dysfunction, and 26 (58%) had preoperative valvular disease. Demographics and comorbidities were similar across all groups. Maturation rates were similar regardless of ejection fraction, presence of diastolic dysfunction, and presence of valvular disease. Primary patency at 6 months and 12 months was similar with respect to ejection fraction or the presence of valvular disease. Primary patency at 6 months and 12 months was 59% and 20% for those with diastolic dysfunction and 69% and 48% for those without diastolic dysfunction (p<0.05).
Conclusion: Technical maturation of hemodialysis access can be achieved equally in patients with or without underlying structural heart disease, but long-term patency remains poor. The presence of any grade diastolic dysfunction, in particular, appears to be associated with poor outcomes. Physicians performing arteriovenous access operations should consider the presence of diastolic dysfunction when assessing the feasibility of successful long-term access.
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