TITLE: Considerations for Long-Term Dialysis Access in Patients with Left Ventricular Assist Devices
BACKGROUND: Renal dysfunction, requiring renal replacement therapy (RRT) is commonly encountered in patients with left ventricular assist devices (LVADs). Continuous flow LVAD (CFLVAD) is the most widely used device. Nonpulsatile blood flow begets special hemodynamic changes. This poses a unique challenge in choosing a long-term dialysis access for patients with CFLVAD where life expectancy is limited.
METHODS: A 61-year-old man with an implanted CFLVAD and renal dysfunction receiving intermittent RRT through a nontunneled dialysis catheter had progressed to dialysis-dependent renal failure. He was referred to us for a permanent hemodialysis access.
RESULTS: The patient underwent a right brachio-brachial arterio-venous graft (AVG) placement. The graft was successfully cannulated for hemodialysis on postoperative day 15. On regular follow-up at 18 months, the graft was still functional.
CONCLUSIONS: Dialysis access for patients on LVAD is an exceptional management problem owing to both altered physiology and guarded overall prognosis. We recommend the use of AVG as a convenient and durable option-facilitating early cannulation and expediting freedom from indwelling catheters that may lead to catastrophic consequences. This should limit the need for secondary interventions, hospitalization, and cost, thus improving quality of life.
SOURCE: Safaya A, Bhuta K, Rajdeo H. Considerations for Long-Term Dialysis Access in Patients with Left Ventricular Assist Devices[J]. Ann Vasc Surg, 2021, 70:568.e13-568.e17. DOI: 10.1016/j.avsg.2020.08.120.
背景：使用左心室辅助装置(LVAD)的患者经常会遇到肾功能不全，需要进行肾脏替代治疗(RRT)。持续血流LVAD(CFLVAD)是目前应用最广泛的设备。非搏动性血流会引起特殊的血流动力学变化。这给预期寿命有限的CFLVAD患者选择长期透析通路带来了独特的挑战。
方法：1例61岁植入CFLVAD且肾功能不全的男性患者，通过非隧道透析导管进行间歇性RRT，进展为透析依赖性肾功能衰竭。他被推荐给我们，为了建立永久性血液透析通路。
结果：患者接受了右臂-肱动脉-肱静脉移植物(AVG)置入术。术后第15天移植物成功穿刺进行血液透析，术后18个月定期随访，移植物仍有功能。
结论：LVAD患者的透析通路是一个特殊的管理问题，因为生理改变和总体预后有限。我们建议使用AVG作为一种方便和持久的、便于早期穿刺的路径，加速从可能导致灾难性后果的留置导管中解脱出来。这应该会限制二次干预的需要、住院和费用，从而提高生活质量。
启发：AVG作为早期穿刺的解决方案，在自体血管耗竭时，是不错的选择，可以减少留置导管带来的不利后果！
