Doppler ultrasonography-guided surgery for high-flow hemodialysis vascular access: preliminary results

We sought to investigate the results of flow reduction with prospective Doppler ultrasonography (USG)-guided surgery.

Thirty patients with end-stage renal failure with high-flow arterio-venous (AV) fistulae (n = 25) or AV grafts (n = 5) were included in the study. The indications for operation were as follows: cardiac failure (n = 18) or steal syndrome (n = 12). AV fistula flow >800 mL/min or AV graft >1200 mL/min was the selection criterion for definition of a high-flow vascular access. The desired postoperative flow was 400 mL/min or 800 mL/min for AV fistula or AV graft, respectively. Before the surgical intervention, a vascular clamp was used to simulate the planned intervention with evaluation by Doppler USG after the anastomosis was narrowed.

There were 16 men and 14 women with a median age of 48 +/- 9 years (range, 39-57 years). Preoperative measurements of median AV fistula, AV graft flow, and anastomosis diameter were as follows: 2663 mL/min (range, 1856-3440 mL/min); 2751 mL/min (range, 2140-3584 mL/min); and 7.3 mm (range, 6.1- 8.5 mm), respectively. The flow was reduced to 615 mL/min (range, 552-810 mL/min) for AV fistulae and 805 mL/min (range, 745-980 mL/min) for AV grafts. The median diameter of the anastomosis was reduced to 4 mm (range, 3.5-4.3 mm). There were no reinterventions. During the median 1-year follow-up, AV fistula and AV graft patency rates were 100% and 80%, respectively and clinical complaints resolved. Cardiac output rate was reduced from 8.5 +/- 2.9 L/min to 6.1 +/- 1.9 L/min (P < .01).

Cardiac failure and steal syndrome resulting from high-flow vascular access can be treated successfully with Doppler USG-guided surgery. The desired anastomotic diameter and flow are limited in cases of excessively dilated efferent veins for vascular access.