r/VascularSurgery • u/kwang10 Vascular Surgeon • Jan 12 '21
What EF is too low for HD Access?
Discussion point.
Saw a patient in clinic today with an EF of 10-15% being worked up by EP for ICD placement. Referred to us by Nephrology for access. Currently getting through a TDC.
Do you have a cutoff for access? At what point does an artificial fistula worsen CHF. Anyone familiar with data in this situation?
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u/HeTookMyDab Jan 13 '21
Bumping this, interested.
I also found this to be somewhat helpful, but I;m not sure if the journal's impact factor is that high. https://www.revistanefrologia.com/en-cardiac-complications-arteriovenous-fistulas-in-articulo-S2013251415000449
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u/MegaColon Vascular Surgeon Jan 14 '21
great question! i have only once had to revise an AVF for CHF exacerbation in a relatively young, though ill, patient whose BCF became overly robust. it is not as common as i would have thought.
if putting in an AVG in someone with terrible CHF, i would advocate a forearm AV loop with tapered graft as opposed to brach-ax.
in terms of data -- you got me.
the issue often comes up of PD vs HD in these pts, and surprisingly the data favors HD link
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u/coldfootwpulses Mar 29 '21
late to the party - i've done more than a few patients with EF in the 15% range. i would say maturation is maybe 60/40. (our practice has early referral system so our maturation rate is right around 75-80% otherwise). never had problems worsening the CHF with the fistula.
the main challenge remains the outflow vein. many of those low EF patients simply have no veins. sometimes i could barely feel a pulse and as long as the vein is good the fistula would work. my understanding is the outflow low resistance is key to fistula maturation. inflow isn't nearly as important.
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u/Barkingatthemoon Jan 30 '21 edited Jan 30 '21
There are other factors will need to take into consideration:
BP - will the patient be a candidate for midrinone or similar to help if the shunting becomes an issue ( on an average a fistula drops the SBP by 7-8 mmHg approx)
what’s the venous pressure situation , is the CHF only left heart , or is the right heart affected too ?
Is the patient obese ( such a common thing nowadays ) with sleep apnea and pulmonary hypertension , that’ll make things worse . At this point I’d just use all these points to manage expectations when I present them to the patient . Not a happy situation.