Cure of Refractory Hypotension in a Hemodialysis Patient

We present a case of a 67-year-old male with end-stage renal disease (ESRD) on hemodialysis who was admitted to the hospital after recurrent falls secondary to postural hypotension. He was not able to tolerate fluid removal on dialysis due to persistent hypotension despite maximal doses of midodrine and developed severe edema. A right heart catheterization revealed raised biventricular filling pressure consistent with right heart failure with low systemic vascular resistance and pulmonary hypertension. Duplex ultrasound of the left arm cephalic arteriovenous fistula (AVF) revealed a blood flow of 5.6 L/min. We hypothesized the cause of his high output heart failure from an AV fistula despite the lack of an increase in blood pressure after compression of the AVF. The AVF was ligated and a tunneled hemodialysis catheter was placed. Immediately after ligation, the patient was able to tolerate fluid removal with dialysis without hypotension, leading to a significant improvement in his edema and shortness of breath. This case highlights the potential adverse cardiovascular effects of AVF and the salutary effects on ligation in appropriate clinical settings.