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Long Term Echocardiographic Changes After High Flow Vascular Access Creation
Levester Kirksey, MD, Khan Abdullah, MD,
Enrico Prajiante Bertolino, MD, Ahmed Sorour, MD, J. Emanuel Finet, MD, Tushar J Vachharajani, MD, Heba Wassif, MD, Jon Quatromoni, Francis J. Caputo, MD, Sean P. Lyden, MD.
The Cleveland Clinic Foundation, Cleveland, OH, USA.
OBJECTIVES: The provision of renal replacement therapy for the end stage kidney disease (ESKD) patient is lifesaving therapy. Surgically created arteriovenous access (SAA) is the most utilized modality. Positive remodeling may occur following SAA leading to high flow vascular access (HFVA). The impact of long-term exposure to HFVA on remodeling of cardiac structures is not well understood. Accordingly, this study describes the echocardiographic changes observed in HFVA following SAA creation.
METHODS: This single-center retrospective study included all patients with HFVA, defined as volume flow (Qa) > 2000 ml/min, from January 2014 to December 2024. A comprehensive chart review was conducted to document patient demographics, SAA configuration, and echocardiographic data. Echocardiographic data was evaluated before and after SAA creation at serial time intervals and changes were compared.
RESULTS: 201 patients were included, with an average age of 57 years and a median Qa of 2338 ml/min (2189, 2787). The cohort comprised of 31% females and 68% Black American patients. The predominant SAA location was the upper arm (87%), and configuration was brachial artery-basilic vein (42%). Significant echocardiographic changes were observed over time: Left atrial volume (LAV) and left ventricular end-diastolic volume (LVEDV) both increased after 6 months and peaked after 5 years (LAV: +17.6; LVEDV: +25.2, p<0.01). Estimated right ventricular systolic pressure (eRVSP) also increased at 6 months, peaking at 5 years (+9.9; p<0.01). Left ventricular stroke volume (LVSV) showed an increase at 6-12 months (+6.7, p<0.05). Left ventricular ejection fraction (LVEF) significantly decreased after 5 years (-3.3; p<0.01). The left ventricular mass index (LVMI) (p=0.34) and estimated right atrial pressure (eRAP) (p=0.05) did not change significantly.
(Table I)
CONCLUSIONS: In patients with HFVA following SAA, cardiac remodeling is observed as early as 6 months. At five years, HFVA exposure uniformly produced progressive decline of key echocardiographic parameters associated with heart failure. Our observations underscore the importance of routine surveillance of the vascular access circuit and cardiac structures to characterize remodeling. When monitoring patients with HFVA, consideration should be given to surgical revision with a goal of volume flow reduction prior to the development of clinical deterioration
Echocardiographic Parameters Change Over Time| Echocardiography | Baseline Echo | 6-12m: Diff | 6-12m: P value | 1-3y: Diff | 1-3y: P value | 3-5y: Diff | 3-5y: P value | 5+ y: Diff | 5+ y: P value |
| LAD | 4.15 (4.02,4.27) | 0.20 (-0.04,0.44) | 0.098 | 0.24 (0.07,0.42) | 0.006 | 0.37 (0.16,0.59) | <0.001 | 0.45 (0.23,0.67) | <0.001 |
| LAV | 77.2 (71.9,82.5) | 11.6 (3.3,20.0) | 0.007 | 11.7 (5.2,18.2) | <0.001 | 14.2 (6.7,21.7) | <0.001 | 17.6 (9.9,25.2) | <0.001 |
| LVSV | 71.2 (67.3,75.0) | 6.7 (0.6,12.8) | 0.031 | 4.9 (0.3,9.6) | 0.039 | 1.8 (-3.7,7.2) | 0.52 | 5.2 (-0.5,10.9) | 0.075 |
| LVEF | 56.8 (55.3,58.3) | -0.2 (-2.3,1.9) | 0.84 | -1.4 (-3.0,0.2) | 0.091 | -1.7 (-3.6,0.3) | 0.095 | -3.3 (-5.5,-1.1) | 0.003 |
| LVMI | 124.8 (117.3,132.2) | 3.8 (-6.3,13.9) | 0.46 | 7.6 (-0.4,15.6) | 0.064 | 6.9 (-2.6,16.5) | 0.15 | 5.0 (-5.3,15.3) | 0.34 |
| LVEDV | 124.3 (116.8,131.9) | 14.9 (4.7,25.1) | 0.004 | 16.0 (7.9,24.1) | <0.001 | 13.3 (3.6,23.0) | 0.007 | 25.2 (14.5,35.9) | <0.001 |
| LVESV | 56.5 (50.8,62.2) | 9.8 (3.0,16.7) | 0.005 | 9.0 (3.3,14.7) | 0.002 | 7.5 (0.8,14.3) | 0.028 | 17.5 (9.7,25.2) | <0.001 |
| eRVSP | 34.3 (31.6,37.0) | 3.3 (-1.4,8.0) | 0.17 | 6.1 (2.7,9.4) | <0.001 | 6.9 (3.0,10.8) | <0.001 | 9.9 (6.0,13.7) | <0.001 |
| eRAP | 6.7 (5.9,7.6) | -0.4 (-2.0,1.2) | 0.64 | 0.6 (-0.5,1.7) | 0.27 | 0.2 (-1.0,1.5) | 0.72 | 1.2 (-0.0,2.4) | 0.051 |
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