High-output Congestive Failure From Femoral Arteriovenous Shunts for Vascular Access HENRY J. FEE, M.D., JORGE LEVISMAN, M.D., ROBERT B. DOUD, M.D., ARTHUR L. GOLDING, M.D.
Femoral arteriovenous bovine shunts (FAVBS) represent an From the Departments of Surgery and Medicine, accepted method of vascular access for patients requiring UCLA School of Medicine, chronic hemodialysis. The authors present 4 patients who reLos Angeles, California 90024 quired corrective surgery for high-output congestive heart failure (HOCHF) secondary to high flow rates through the shunt. In order to avoid this serious complication, intraoperative graft flow rates should not exceed 900 cc/min. HOCHF secondary a left groin reverse saphenous vein graft approximately 3 years prior to FAVBS may be refractory to conservative therapy and require to this report and postoperatively did well. Two years postshunting, however, she developed exertional shortness of breath either banding of the shunt or its removal.
T HE DEVELOPMENT of high-output congestive heart failure (HOCHF) subsequent to traumatic AVF is a well-documented phenomenon.3 However, in the literature there are no reports of HOCHF secondary to surgically created arteriovenous fistula (AVF) for vascular access in patients who are on chronic hemodialysis. This report concerns 4 patients who developed HOCHF secondary to large flows through their femoral arteriovenous bovine shunts (FAVBS) who required surgical correction for this condition. Methods The charts of 165 consecutive patients who during the last 5 years have received bovine or reverse saphenous vein grafts in the groin for vascular access were reviewed for evidence of HOCHF. A number of these patients developed symptoms of congestive heart failure (CHF) after shunting; most of them were controlled with hemodialysis. However, there were 4 patients who developed severe symptoms and were found to exhibit exceptionally high flow through the grafts which eventually required surgical intervention.
and was noted to have aneurysmal dilatation of the saphenous vein graft. A chest x-ray, which had been normal preoperatively, showed an increase in the cardiothoracic ratio. The electrocardiogram was unchanged. Because of the rapid progression to CHF, a cardiac catheterization was performed which demonstrated a 4.9-1/min flow through the graft. The graft was banded and shunt flow was decreased to 2.2 I/min. The saphenous vein graft was noted to be markedly aneurysmal, and in some areas had a diameter of 3 cm. After the banding procedure, the patient's symptoms continued to persist, and a repeat cardiac catheterization showed that her output remained high at 9.7 1/min and the cardiac index was 5.0 I/min. After 3 minutes of saphenous vein compression, the cardiac output fell to 8.5 1/min with a cardiac index of 4.4 I/min. The saphenous vein was replaced with a left FAVBS which thrombosed in the immediate postoperative period. An arm bovine shunt was placed for chronic dialysis. She then had resolution of her symptoms of high output cardiac failure: the dyspnea disappeared, the size of the heart decreased, and the cardiac index returned to normal.
Comment. This patient was markedly symptomatic and catheterization studies demonstrated a 4.9-1/min flow through the graft. Decreasing this flow to 2.2 1/min neither relieved her symptoms, nor did she become asymptomatic until the graft thrombosed.
Case 2. A 60-year-old hypertensive man with chronic renal failure secondary to chronic polynephritis and a past history of an anterior myocardial infarction (MI) without CHF had a left FAVBS approximately 1 year prior to this report. Postoperatively he Case Reports developed an EKG pattern which was compatible with another MI; Case 1. A normotensive 20-year-old woman with chronic renal however, he remained asymptomatic for 6 months with a functioning failure secondary to glomerulonephritis had received multiple shunts shunt. He then developed symptoms of angina, and 2 months for chronic hemodialysis during the past 3½ years. She underwent later developed frank congestive heart failure with pulmonary edema. He was started on Digoxin, which brought about only mild improveSubmitted for publication September 29, 1975. ment. It was felt that the congestive failure was an HOCHF and
Ann. Surg. March 1976 FEE AND OTHERS consequently, cardiac catheterization was performed. A 1.6-1/min flow may have been reduced and thus a 3.1 1/min flow through the bovine shunt was demonstrated, and the shunt was then through the shunt severely compromised myocardial banded, reducing the flow from 1.61 to 1.0 I/min. The patient showed function. Reduction in flow from 3.1 1/min to 0.3 1/min dramatic improvement; he has had no further dyspnea or angina. eliminated the HOCHF syndrome. Comment. This patient evidenced moderate flow Results through the shunt, but he was hypertensive and had successful was of the shunt a MI. Banding experienced From our limited experience with HOCHF secondary and he has remained asymptomatic for the last 12 FAVBS, it would appear that shunt banding is a to months. reasonable therapeutic approach once cardiac output Case 3. A 33-year-old woman with juvenile onset diabetes mellitus studies have documented high flows. In three patients and chronic renal failure due to Kimmelstiel-Wilson syndrome under- with bovine shunts which were banded, all became went a left FAVBS. She did well for approximately 1 week, but asymptomatic. Two shunts remained patent and the then developed symptoms of dyspnea and chest pain, and on physical third thrombosed. In the fourth patient (Case 1), flow examination was noted to have an S3 gallop. Chest x-ray revealed was only decreased to 2.2 1/min, and symptoms persisted a large bilateral pleural effusion and an increase in cardiothoracic ratio. After digitalization and fluid restriction, she showed only until a second operation was performed. It would therepartial improvement and it was felt that she had HOCHF. Inter- fore appear that flows should be adjusted to between 0.3 operative shunt flow was measured at 2.8 I/min and after banding, and 0.9 1/min in order to maintain shunt patency with it was 0.2 I/min. Postoperatively the dyspnea and chest pain dis- adequate flows for dialysis and yet elminate significant appeared, the gallop was not audible, and chest x-ray showed marked shunting that could cause HOCHF. reduction of the pleural effusion with return of the cardiothoracic 9
ratio to normal. The patient remained asymptomatic; however, 2 weeks postoperatively, the bovine shunt thrombosed.
Comment. This patient developed HOCHF 1 week after shunting. Because of severe juvenile diabetes, she may have had coronary atherosclerosis and decreased cardiac reserve. In fact, there was arteriographic evidence of significant arteriosclerosis of the lower
extremity. This patient was successfully banded even though the shunt thrombosed soon after surgery. The corrected flow, which measured only 0.2 1/min, was inadequate to maintain shunt patency. Case 4. A 51-year-old normotensive woman with systemic lupus erythematosis (SLE) and chronic renal failure requiring chronic hemodialysis had experienced frequent episodes of thrombosis of the AV shunts, eventually requiring placement of an FAVBS. Prior to surgery, the patient suffered an upper gastrointestinal bleed and showed electrocardiographic changes of a subendocardial MI. Within 48 hours after placement of the bovine shunt, the patient became obtunded, with bibasilar wet rales, an S3 gallop, and distended jugular veins. Radiographic studies demonstrated marked cardiomegaly, increased pulmonary vascularity, and bilateral pleural effusions. Cardiac output was measured at 8.0 I/min which decreased to 4.9 I/min upon manual occlusion of the shunt. The bovine shunt was then banded and intraoperative flows were decreased from 3.1 I/min to 0.3 1/min. Banding of the bovine shunt led to marked improvement: a decrease in cardiac size, the disappearance of S3 gallop, and a rise in Pan,. However, the patient suffered from recurrent pulmonary infections, hepatic dysfunction and coma of unknown etiology, and she eventually died 26 days later.
Comment. With a possible subendocardiac MI and long-standing SLE, the patient's myocardial reserve
The size of the shunt and the existence of underlying cardiac disease are the two major risk factors in developing HOCHF. In bovine shunts the fistula is approximately 7 mm in diameter by 35 cm in length. When placed in the groin there is very little venous resistance, thus permitting high fistula flow. This high flow state is most significant in this patient population, inasmuch as at least 50o of deaths in patients on chronic hemodialysis are due to cardiovascular causes, implying compromised myocardial reserve.2 The accelerated atherosclerosis that occurs in patients with chronic renal failure predisposes them to significant coronary artery disease and frank myocardial infarction, both of which lead to decreased cardiac reserve and diminished ventricular compliance. Such hemodynamic compromise makes these patients less able to tolerate the stress of the increased cardiac work occurring with FAVBS. The fact that this work load can be significant was demonstrated in a recent study by our group. Of 17 patients with FAVBS who had cardiac outputs determined by echocardiography, 12 (71%) had a 20% or more reduction in cardiac output, with manual occlusion of the shunt.1 With the use of FAVBS for vascular access, the factor of patient selection is most important. Three of the 4 patients in this report showed indications of myocardial compromise; one had a history of hypertension and MI, one of severe juvenile diabetes, and the third reported a background of SLE and an MI. Severe
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FEMORAL ARTERIOVENOUS BOVINE SHUNTS
hypertension, diabetes mellitus, history of MI or the of a systemic disease associated with a cardiomyopathy are certainly significant risk factors. However, once the decision has been made to place an FAVBS in the patient, careful regulation of flow ranging between 300 and 900 cc/minute should be done intraoperatively. Postoperatively, the patient should be watched closely for signs or symptoms of CHF. presence
1. Fee, H. J., Levisman, J., Dickmeyer. J. and Golding, A. L.: Hemodynamic Consequences of Femoral Arteriovenous Fistula. (Submitted for publication.) 2. Lowrie, E. G.. Lazarus, J. M., Hampers. C. L., and Merrill. J. P.: Cardiovascular Disease in Dialysis Patients. N. EngI. J. Med., 290:737, 1974. 3. Warren, J. V., Nickerson, J. L., and Elkin, D. C.: The Cardiac Output in Patients with Arteriovenous Fistulas. J. Clin. Invest., 30:210, 1955.