Long-term echocardiographic trajectories after high-flow vascular access creation

The provision of renal replacement therapy for patient with end-stage kidney disease is lifesaving therapy. Surgically created arteriovenous access (SAA) is the most used 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.

This single-center retrospective study included all patients with HFVA, defined as volume flow > 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.

A total of 201 patients were included, with an average age of 57 years and a median volume flow of 2338 mL/min (interquartile range, 2189-2787 mL/min). 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 to 3 years, most remaining parameters worsened significantly, and notably right ventricular (RV) systolic pressure. LV ejection fraction significantly decreased after 5 years (P < .01), and LV mass index did not change significantly (P = .34). RV and LV dilation and dysfunction were significant at 1 to 3 years. Most importantly, any degree of RV dilatation (hazard ratio, 2.83; P = .007) or RV systolic dysfunction (hazard ratio, 2.36; P = .017) was independently associated with early mortality.

In patients with HFVA, cardiac remodeling was observed as early as 6 months. After 1 to 3 years of HFVA exposure, progressive decline in key echocardiographic parameters related to heart failure was observed. 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.