Heart Failure Following Arteriovenous Fistula Secondary To Penetrating Trauma: Systematic Review And Individual Patient Data Meta-analysis
Florian A. Wenzl, MD1, Mohan Satish, BS2, Sarah J. Aurit, MS1, Stephanie S. Miljkovic, MS2, Parinaz J. Dabestani, MA BS2, Juan A. Asensio, MD, FACS, FCCM, FRCS (England), KM1.
1Creighton University, Omaha, NE, USA, 2Creighton University School of Medicine, Omaha, NE, USA.
OBJECTIVES: High-output cardiac failure is a well-recognized serious complication of arteriovenous fistulas (AVFs) leading to severe sequelae such as pulmonary hypertension. The majority of acquired AVFs are secondary to penetrating traumatic injuries. We aimed to identify predictors for heart failure (HF) in patients presenting with AVFs after penetrating trauma.
METHODS: Both MEDLINE and CINAHL were searched (up to June 2019) for case reports, retrospective cohort studies and prospective studies that reported individual patient data on baseline patient characteristics and feeding artery of AVF secondary to penetrating trauma. Univariate and multivariate analyses were conducted on the collected individual patient data.
RESULTS: There were 320 patients with AVF following penetrating trauma identified from 227 studies. Median age at presentation was 32 years (IQR: 18-79), 88% were males. Most frequent injuries were stab wounds (43%) and gunshot wounds (34%). AVF location was neck (71 [22%] patients), thorax (50 [16%]), abdomen (103 [32%]), upper limb (11 [3%]), and lower limb (85 [27%]). A total of 48 (15%) patients presented with HF and 272 (85%) presented with other symptoms. HF was associated with longer time from injury to presentation with AVF (p<0.001), older median age at presentation (41.5 vs. 30.0 years; p<0.01), presence of large feeding arteries (aorta, pulmonary artery, iliac arteries) of AVF (41.7% vs. 13.6% of patients; p<0.001), and injury of thorax, abdomen or lower limb (93.8% vs 71.0% of patients; p=0.001). After adjusting for patient and injury characteristics, it was found that large feeding arteries of AVF (OR = 5.50; 95% CI: 2.38-12.74) and every six years of delay in presentation (OR = 1.33; 95% CI: 1.05-1.67) were independent predictors for HF. CONCLUSIONS: Larger feeding arteries and delayed presentation independently predict heart failure in patients presenting with AVF secondary to penetrating trauma. Vascular screening requires prospective evaluation for trauma patients at risk for developing HF from AVFs.
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