Hemodynamic Effects of Left Upper Extremity Arteriovenous Fistula on Ipsilateral Internal Mammary Coronary Artery Bypass Graft

Abstract

Objective Arteriovenous fistula (AVF) in patients undergoing hemodialysis (HD) may cause coronary left internal mammary artery (IMA) steal. This phenomenon was demonstrated by few prospective studies with limited number of patients and case reports. We aimed to demonstrate with a relatively larger patient population that the AVF may cause ipsilateral IMA steal.

Methods We included 22 prospective patients undergoing HD who had left IMA to left anterior descending artery graft and left upper limb AVF. Right IMA was taken as control. Flows were assessed by using color Doppler ultrasonography.

Results The mean age was 57.8 ± 9 years. Statistically nonsignificant increases in AVF flow and decreases in left IMA flow were observed during HD compared with pre-HD. Moreover, fistula localization did not affect median left IMA flows (for peak systolic velocity [PSV] 43.7 versus 70 cm/s, respectively; p = 0.7, and for end diastolic velocity [EDV] 3.4 versus 6.5 cm/s, respectively; p = 0.7). We have not detected significant difference in left IMA flows during HD (median values of PSV 58.4 versus 68.4 cm/s, respectively; p = 0.1, and EDV 6.4 versus 4.4 cm/s, respectively; p = 0.08). Only three patients experienced dialysis-induced reduction of ipsilateral IMA flow that was accompanied by evidence of hypokinesia of the anterior left ventricular wall without clinical angina.

Conclusions Hemodynamically affected left IMA flow by ipsilateral upper extremity AVF may cause steal phenomenon. Hemodynamic differences between left and right IMAs in patients undergoing HD via left wrist and brachial fistulae are limited.

Keywords

hemodialysis - arteriovenous fistula - coronary steal - coronary bypass surgery

• References

• 1 Mailloux LU, Bellucci AG, Wilkes BM , et al. Mortality in dialysis patients: analysis of the causes of death. Am J Kidney Dis 1991; 18 (3) 326-335
• 2 Agirbasli M, Weintraub WS, Chang GL , et al. Outcome of coronary revascularization in patients on renal dialysis. Am J Cardiol 2000; 86 (4) 395-399
• 3 Cameron A, Kemp Jr HG, Green GE. Bypass surgery with the internal mammary artery graft: 15.  year follow-up. Circulation 1986; 74 (5 Pt 2) III30-III36
• 4 Loop FD, Lytle BW, Cosgrove DM , et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986; 314 (1) 1-6
• 5 Rahbar R, McGee WR, Birdas TJ, Muluk S, Magovern J, Maher T. Upper extremity arteriovenous fistulas induce modest hemodynamic effect on the in situ internal thoracic artery. Ann Thorac Surg 2006; 81 (1) 145-147
• 6 Gaudino M, Serricchio M, Luciani N , et al. Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula. Circulation 2003; 107 (21) 2653-2655
• 7 Elian D, Gerniak A, Guetta V , et al. Subclavian coronary steal syndrome: an obligatory common fate between subclavian artery, internal mammary graft and coronary circulation. Cardiology 2002; 97 (4) 175-179
• 8 Rossum AC, Steel SR, Hartshorne MF. Evaluation of coronary subclavian steal syndrome using sestamibi imaging and duplex scanning with observed vertebral subclavian steal. Clin Cardiol 2000; 23 (3) 226-229
• 9 Schenk III WG. Subclavian steal syndrome from high-output brachiocephalic arteriovenous fistula: a previously undescribed complication of dialysis access. J Vasc Surg 2001; 33 (4) 883-885
• 10 Kato H, Ikawa S, Hayashi A, Yokoyama K. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003; 75 (1) 270-271
• 11 Calafiore AM, Giammarco GD, Teodori G , et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996; 61 (6) 1658-1663 , discussion 1664–1665
• 12 Crowley SD, Butterly DW, Peter RH, Schwab SJ. Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis 2002; 40 (4) 852-855
• 13 Frank CW, Wang HH, Lammerant J, Miller R, Wegria R. An experimental study of the immediate hemodynamic adjustments to acute arteriovenous fistulae of various sizes. J Clin Invest 1955; 34 (5) 722-731
• 14 De palma JR, Vannix R, Bahuth J, Abukurah A. ''Steal'' syndrome, ischemia, congestive failure, and peripheral neuropathy. Proc Clin Dial Transplant Forum 1973; 3: 9-11
• 15 Oudenhoven LF, Pattynama PM, de Roos A, Seeverens HJ, Rebergen SA, Chang PC. Magnetic resonance, a new method for measuring blood flow in hemodialysis fistulae. Kidney Int 1994; 45 (3) 884-889
• 16 Gaudino M, Serricchio M, Tondi P , et al. Non-invasive evaluation of mammary artery flow reserve and adequacy to increased myocardial oxygen demand. Eur J Cardiothorac Surg 1998; 13 (4) 404-409
• 17 Kinoshita T, Asai T, Ishigaki T. Steal from skeletonized internal thoracic artery graft during hemodialysis after coronary artery bypass grafting. Heart Surg Forum 2010; 13 (4) E254-E256

• References

• 1 Coskun I, Colkesen Y, Altay H , et al. Hemodynamic effects of left upper extremity arteriovenous fistula on ipsilateral internal mammary coronary artery bypass graft. Thorac Cardiovasc Surg 2012; 61 (8) 663-668
• 2 Kato H, Ikawa S, Hayashi A, Yokoyama K. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003; 75 (1) 270-271
• 3 Gaudino M, Serricchio M, Luciani N , et al. Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula. Circulation 2003; 107 (21) 2653-2655
• 4 Kinoshita T, Asai T, Ishigaki T. Steal from skeletonized internal thoracic artery graft during hemodialysis after coronary artery bypass grafting. Heart Surg Forum 2010; 13 (4) E254-E256
• 5 Rahbar R, McGee WR, Birdas TJ, Muluk S, Magovern J, Maher T. Upper extremity arteriovenous fistulas induce modest hemodynamic effect on the in situ internal thoracic artery. Ann Thorac Surg 2006; 81 (1) 145-147
• 6 Cluzel P, Chabrot P, Citron B , et al. [Aortocoronary bypass, haemodialysis and internal mammary artery steal]. Nephrol Ther 2009; 5 (7) 648-651