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Enhancing Av Fistula Banding Accuracy With Intraoperative Ultrasound
Richard Deane, MD,
Adel Hanandeh, MD, Victor Carbrera, MD, Aditya Rao, MS3, Gerard De Castro, MD, Frederick Fisher, MD.
University of Central Florida, Orlando, FL, USA.
DEMOGRAPHICS:A 55-year-old male with a left brachiocephalic arteriovenous fistula for hemodialysis.
HISTORY:The patient presented with aneurysmal dilation of the AVF, treated with aneurysmorrhaphy. Post-procedure, the AVF exhibited elevated flow, leading to symptoms of congestive heart failure. Echocardiogram showed right heart strain, and duplex ultrasound revealed a volume flow of nearly 4000 cc/min. The excessive flow likely contributed to minimal CHF symptoms. Treatment options included open repair with banding, plication, revision using distal inflow, and endovascular balloon-assisted banding or plication.
PLAN: we opted to perform left upper extremity AVF banding using an 8 mm expanded polytetrafluoroethylene graft. Intraoperative ultrasound was used for real-time volume flow monitoring during banding to ensure accurate adjustment. Preoperative AVF flow was >4000 cc/min. Post-band, flow was reduced to 1100 cc/min. Intraoperative US guided continuous adjustments, allowing real-time flow evaluation. Follow-up at 2-4 weeks showed AVF flow stabilized at 800-1000 cc/min, with reduction in CHF symptoms.
DISCUSSION:Managing high-output AVFs is challenging due to risks including heart failure, AVF thrombosis, or vessel stenosis (Stolic, 2013). Traditional flow regulation methods can be subjective (NKF-DOQI, 1997). Intraoperative US provides objective, real-time data, facilitating precise adjustments (de Castro-Santos et al., 2021). This case demonstrates the benefit of intraoperative US in optimizing AVF flow during banding, enhancing flow dynamics, and reducing complications. Immediate intervention with intraoperative US may minimize re-operation rates and improve AVF patency (Turner al., 2020).Previous studies support the value of objective flow measurement (Malik al., 2022). Turner found that real-time US improved AVF success rates through immediate flow adjustments. These findings support intraoperative US as a crucial tool for better surgical outcomes in high-output AVFs. Further research is needed to validate this technique in larger cohorts.
Work Cited:- Stolic, R. "Most Important Chronic Complications of Arteriovenous Fistulas for Hemodialysis." Med Princ Pract, 2013. DOI: 10.1159/000343669.
- NKF-DOQI. "Clinical Practice Guidelines for Vascular Access." Am J Kidney Dis, 1997, 30 (4 Suppl 3),DOI: 10.1053/j.ajkd.2006.04.040.
- de Castro-Santos, G. et al. "Intraoperative Vascular Doppler Ultrasound Blood Flow, Peak Systolic Velocity Predict Early Patency in Hemodialysis Arteriovenous Fistula." J Vasc Bras, 2021, DOI: 10.1590/1677-5449.210098.
- Malik, J. et al. "Arteriovenous Hemodialysis Access Stenosis Diagnosed by Duplex Doppler Ultrasonography: A Review." Diagnostics (Basel), DOI: 10.3390/diagnostics12081979.
- Turner, A. D. et al. "Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula Causing High Cardiac Output Heart Failure." Ann Vasc Surg,DOI: 10.1016/j.avsg.2019.12.011
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