Permanent arteriovenous fistula or catheter dialysis for heart failure patients

Area of Science:

• Nephrology
• Cardiology
• Vascular Surgery

Background:

• Heart failure (HF) is a common comorbidity in chronic kidney disease (CKD) patients undergoing hemodialysis (HD).
• Incident HD patients with HF face elevated cardiovascular mortality risk, particularly during arteriovenous fistula (AVF) maturation and early HD treatment (first 120 days).
• Hemodynamic changes from AVF creation can exacerbate HF, necessitating careful vascular access planning.

Purpose of the Study:

• To guide vascular access selection for incident hemodialysis patients with heart failure.
• To stratify risk based on heart failure severity and recommend appropriate vascular access strategies.
• To optimize outcomes by individualizing AVF versus tunneled catheter placement.

Main Methods:

• Review of clinical guidelines and evidence regarding vascular access in heart failure patients initiating hemodialysis.
• Stratification of heart failure patients based on New York Heart Association (NYHA) functional classification and American College of Cardiology/American Heart Association (ACC/AHA) stages.
• Analysis of risks associated with arteriovenous fistula (AVF) creation versus tunneled central catheter placement.

Main Results:

• HF patients NYHA Class I-II / ACC/AHA Stage A-B may initiate HD with a distal arm AVF.
• High-flow brachial artery-based AVF creation should be avoided due to increased risk of cardiac function deterioration.
• Individualized decisions for AVF or tunneled catheter are recommended for NYHA Class III / ACC/AHA Stage C patients based on cardiac dysfunction.
• NYHA Class IV / ACC/AHA Stage D patients with significantly reduced ejection fraction (<30%) are candidates for tunneled catheter placement.

Conclusions:

• Vascular access planning for incident HD patients with HF requires careful risk assessment of both AVF creation and catheter complications.
• Distal AVF is appropriate for early-stage HF, while high-flow AVF should be avoided.
• Advanced HF necessitates individualized vascular access strategies, often favoring tunneled catheters for severe systolic dysfunction.