Long Term Echocardiographic Trajectories After High Flow Vascular Access Creation

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 cardiovascular structural remodeling 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, over a 10-year period. Electronic medical records were reviewed to extract demographic, clinical, and echocardiographic data before and after SAA creation at serial intervals. Changes in echocardiographic parameters were compared using paired analyses. Univariable and multivariable Cox regression models assessed mortality, ventricular dilatation, and dysfunction.

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. SAA were predominantly in the upper arm (87%), brachial-basilic (42%) and autogenous (89%). Significant echocardiographic changes were observed over time: Left atrial volume and left ventricular (LV) end-diastolic volume worsened after 6 months. At 1-3 years, most remaining parameters worsened significantly, and notably the right ventricle (RV) systolic pressure (. LV ejection fraction (LVEF) significantly decreased after 5 years (p<0.01), and LV mass index did not change significantly (p=0.34). RV and LV dilation and dysfunction were significant at 1-3 years. Most importantly, any degree of RV dilatation (HR 2.83; p 0.007) or RV systolic dysfunction (HR 2.36; p 0.017) was independently associated with early mortality.

In patients with HFVA, cardiac remodeling was observed as early as 6 months. After 1-3 years' timeline, HFVA exposure was associated with progressive decline of key echocardiographic parameters related to heart failure. These findings underscore the importance of routine surveillance of the vascular access circuit and cardiac structures to detect early remodeling. Close monitoring of worsening RV parameters is essential, as it independently correlates with early mortality risk.