Cardiovascular Implantable Electronic Devices in Hemodialysis Patients: Prevalence and Implications for Arteriovenous Hemodialysis Access Interventions Theodore F. Saad,*† Waqas Ahmed,*† Karen Davis,* and Claudine Jurkovitz‡ *Nephrology Associates, PA, Vascular Access Center, Newark, DE, †Section of Renal & Hypertensive Diseases, Department of Medicine, Christiana Care Health System, Newark, DE, and ‡Value Institute Christiana Care Health System, John H. Ammon Education Center, Newark, DE
ABSTRACT Cardiovascular implantable electronic devices (CIEDs) are frequently utilized in hemodialysis patients. CIED leads are typically implanted via the subclavian vein resulting in stenosis and venous hypertension. We studied 1235 chronic hemodialysis patients under the care of our nephrology practice. For each, we determined the presence of a CIED, indication for implantable cardioverter-defibrillator (ICD), and type of hemodialysis access. Records were reviewed to identify all interventions performed on the access circuit and the central veins specifically. A CIED was present in 129 patients (10.5%), including ICDs in 75 (6.1%) and pacemakers in 54 (4.4%). The access circuit intervention rate was 1.48/access year (AY) and was
similar when a CIED was ipsilateral (1.53/AY) or contralateral (1.44/AY) to arteriovenous access (p = 0.477). The rate of central venous interventions was greater in the ipsilateral (0.59/AY) versus contralateral group (0.28/AY), (p < 0.001). Fifty-four of 59 patients with ipsilateral access and CIED required 90% of ICD implantations in dialysis patients prior to 2001 were for secondary prevention, whereas in 2005, ICD use for primary prevention had increased up to 51% of implantations (2). In a substantial number of study patients (17/75, 25%), the original indication for ICD implantation could not be determined. This is due to limited information available from the hospital and office electronic health records approved for review under this IRB approval; cardiology office records were not reviewed. We have observed that many patients do not reliably distinguish between primary and secondary prevention and therefore did not rely upon patient-reported indications alone. Stenosis of the subclavian veins and associated venous hypertension could be entirely avoided by use of nontransvenous CIED leads. The successful use of epicardial leads has been reported and may be preferred over transvenous leads for some patients with chronic kidney disease or ESRD who require a CIED (32). Recently, an entirely subcutaneous ICD has been introduced for treatment of ventricular dysrhythmias in a nonrandomized study (33). Because of the problems associated with transvenous CIED leads and AV access, this device may hold particular promise for use in hemodialysis patients (34). Conclusions CIEDs were present in 10.5% of the hemodialysis patients described in this study, with 6.1% having ICDs. These numbers are higher than those previously reported and greater than predicted by USRDS reported rates of ICD implantation. The majority of ICDs were implanted for primary prevention of sudden cardiac death. Overall rates of access circuit intervention were no different for ipsilateral versus contralateral instances of CIED and AV access. Intervention rates for central vein stenosis were higher for CIED leads ipsilateral versus contralateral to AV access. However, 58% in the ipsilateral group required no central vein interventions and 34% required
ABSTRACT Cardiovascular implantable electronic devices (CIEDs) are frequently utilized in hemodialysis patients. CIED leads are typically implanted via the subclavian vein resulting in stenosis and venous hypertension. We studied 1235 chronic hemodialysis patients under the care of our nephrology practice. For each, we determined the presence of a CIED, indication for implantable cardioverter-defibrillator (ICD), and type of hemodialysis access. Records were reviewed to identify all interventions performed on the access circuit and the central veins specifically. A CIED was present in 129 patients (10.5%), including ICDs in 75 (6.1%) and pacemakers in 54 (4.4%). The access circuit intervention rate was 1.48/access year (AY) and was
similar when a CIED was ipsilateral (1.53/AY) or contralateral (1.44/AY) to arteriovenous access (p = 0.477). The rate of central venous interventions was greater in the ipsilateral (0.59/AY) versus contralateral group (0.28/AY), (p < 0.001). Fifty-four of 59 patients with ipsilateral access and CIED required 90% of ICD implantations in dialysis patients prior to 2001 were for secondary prevention, whereas in 2005, ICD use for primary prevention had increased up to 51% of implantations (2). In a substantial number of study patients (17/75, 25%), the original indication for ICD implantation could not be determined. This is due to limited information available from the hospital and office electronic health records approved for review under this IRB approval; cardiology office records were not reviewed. We have observed that many patients do not reliably distinguish between primary and secondary prevention and therefore did not rely upon patient-reported indications alone. Stenosis of the subclavian veins and associated venous hypertension could be entirely avoided by use of nontransvenous CIED leads. The successful use of epicardial leads has been reported and may be preferred over transvenous leads for some patients with chronic kidney disease or ESRD who require a CIED (32). Recently, an entirely subcutaneous ICD has been introduced for treatment of ventricular dysrhythmias in a nonrandomized study (33). Because of the problems associated with transvenous CIED leads and AV access, this device may hold particular promise for use in hemodialysis patients (34). Conclusions CIEDs were present in 10.5% of the hemodialysis patients described in this study, with 6.1% having ICDs. These numbers are higher than those previously reported and greater than predicted by USRDS reported rates of ICD implantation. The majority of ICDs were implanted for primary prevention of sudden cardiac death. Overall rates of access circuit intervention were no different for ipsilateral versus contralateral instances of CIED and AV access. Intervention rates for central vein stenosis were higher for CIED leads ipsilateral versus contralateral to AV access. However, 58% in the ipsilateral group required no central vein interventions and 34% required
