High-Output Cardiac Failure and Coronary Steal With an Arteriovenous Fistula

Area of Science:

• Cardiovascular Medicine
• Nephrology

Background:

• End-stage renal disease (ESRD) necessitates hemodialysis, often requiring arteriovenous (AV) access.
• AV access creation can significantly alter cardiovascular hemodynamics.
• Patients with complex cardiovascular disease present unique challenges for AV access management.

Observation:

• A 78-year-old male with ESRD, coronary artery disease (CAD) with prior coronary artery bypass grafting (CABG) including a left internal mammary artery (LIMA) graft, ischemic cardiomyopathy, and severe aortic stenosis developed refractory hypotension.
• The hypotension occurred after angioplasty of an ipsilateral AV fistula for outflow stenosis.
• This clinical scenario suggests a potential link between AV access, hemodynamics, and compromised coronary perfusion.

Findings:

• The patient's hypotension was attributed to high-output cardiac failure and coronary artery steal syndrome secondary to the AV fistula.
• Banding the AV fistula successfully reduced cardiac output and alleviated hypotension.
• This case underscores the potential for AV access to exacerbate underlying cardiovascular conditions.

Implications:

• AV access in patients with LIMA grafts requires careful consideration to prevent coronary artery steal syndrome.
• Avoiding ipsilateral AV access creation in patients with LIMA grafts may be a crucial preventive strategy.
• Management of AV access in complex cardiac patients necessitates a multidisciplinary approach to optimize outcomes.