ASDIN Original Investigations Inflow Reduction by Distalization of Anastomosis Treats Efficiently High-Inflow High-Cardiac Output Vascular Access for Hemodialysis Eric S. Chemla, Mohamed Morsy, Liz Anderson, and Andrea Whitemore South West Thames Surrey and Sussex Renal Transplant Network, London, United Kingdom ABSTRACT The arteriovenous fistula used for vascular access for hemodi- alysis may contribute to development of congestive heart fail- ure. Theses patients can present with frequent episodes of congestive hear failure. Traditional management of high- inflow, a high-cardiac-output fistula generally involves either closure or banding. Although high-output state can be con- trolled, the lifeline of the patient is lost. We describe a series of 17 hemodialysis patients (10 men and 7 women) in whom a novel inflow reduction method was employed. All patients had symptoms of heart failure (15 brachiocephalic fistulas and two brachioaxillary bypass grafts) and a fistula inflow rate above 1600 ml/min. The inflow reduction procedure included ligation of the brachial anastomosis and reconstruction of the fistula by using an expanded polytetrafluoroethylene (Gore-Tex Inter- ing) vascular graft in a bypass from the radial artery. The mean ( SD) time between fistula creation and the inflow reduction procedure was 30  17 months. The mean access inflow rate decreased significantly after the inflow reduction procedure, from 3135  692 to 1025  551 ml/min (p ¼0.0001). The mean cardiac output rate decreased from 8  3.1 to 5.6  1.7 l/min (p ¼ 0.001) with resolution of symptoms. During the follow-up period thrombosis or stenosis developed in seven patients, three of whom underwent surgical revision. Thirteen of the seventeen accesses (77%) subjected to the inflow reduction procedure remained patent. Access loss was due to failed fistuloplasty or thrombosis. To our knowledge, this is the first report demonstrating that inflow reduction obtained by distalization of the anastomosis of the access fis- tula is feasible and safe for managing high-inflow, high-car- diac-output fistulas. Longer and larger studies of the inflow reduction procedure and its benefits are needed. Creation of a native arteriovenous fistula or implanta- tion of a graft for vascular access for hemodialysis in a patient with end-stage renal disease (ESRD) may con- tribute to the development of high-output cardiac fail- ure. There is a strong relation between inflow into a fistula and cardiac output (1). The mechanism of access- related cardiac failure in patients undergoing dialysis involves development of a low-resistance outflow tract through the fistula and subsequent cardiac compensa- tion to increase cardiac output and maintain blood pres- sure (2). These patients can experience frequent episodes of heart failure. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (DOQI) guidelines recommend that the fistula inflow rate not be lower than 600 ml/min (3), but mention neither high- inflow fistulas nor an upper-limit inflow value that might necessitate ligation or banding of a fistula (4–7). We describe here a series of patients with ESRD undergoing dialysis in whom high-inflow fistulas (inflow rate > 1600 ml/min) high cardiac output with symp- toms of heart failure were managed by an inflow reduc- tion (IR) procedure involving distalization of the fistula anastomosis. Patients and Methods Patients Since January 2004, all patients in our main hemodial- ysis unit have undergone measurement of their inflow and recirculation rates and, in some cases (patients with symptoms of heart failure), their cardiac output rate with use of a Transonic device (Transonic Systems, Ithaca, NY) every other month during a routine dialysis session. If the inflow rate is > 1600 ml/min, cardiac out- put is measured four times during the dialysis session, twice during the first hour and twice during the last hour. Beginning in February 2004, patients with both an inflow rate above 1600 ml/min and a cardiac output rate > 5 l/min associated with symptoms of heart failure (shortness of breath, swollen ankle, and positive Nikola- doni-Branham test) were informed of the possible effects of a high-inflow fistula on the heart and asked whether they would agree to undergo a procedure designed to allow reduction in the inflow rate of the fistula but Address correspondence to: Eric S. Chemla, BSc, MD, Renal Transplant Unit, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK, or e-mail: eric.chemla@stgeorges. nhs.uk. Seminars in Dialysis—Vol 20, No 1 (January–February) 2007 pp. 68–72 68