JOURNAL OF DULYSIS. l ( 7 ) . 665-676 (1977)
PHYSIOLOGIC RESPONSE PATTERNS TO OCCLUSION OF CLINICWY S I G N I F I m ARTERIOVENOUS FISTUIAS
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Frank B. Cerra, M.D.,
Raphael Shapiro, M.D.. Roland Anthone, M.D., Sidney Anthane, M.D. D i a l y s i s and Acute Care Services Department of Surgery S t a t e University of N e w York a t Buffalo Buffalo General Hoapital 100 High St., Buffalo, Nev York 14203
-
ABSTRACT Seven p a t i e n t s v i t h h e d y n a m i c a l l y s i g n i f i c a n t a r t e r i o v n n o w f i s t u l a s f o r d i a l y s i s angioaccesr v e r e s t u d i e d by multivarient computer ana l y s i s of physiologic d a t a derived from cardiogreen dye d i l u t i o n curve8 and A-VO2 before and a f t e r acute occlusion of t h e i r f i s t u l a s and 'prior t o c l i n i c a l therapy. Three p a t t a r n r of response v e r e characterized. These p a t t e r n s seemed t o be r e l a t e d t o t h e innate v e n t r i c u l a r contract i l i t y s t a t u s , t h e type of medication., t h e prerence of autonomic neuropathy. and t h e i r i n t e r p l a y v i t h a l t e r a t i o n s i n preload and a f t e r l o a d v i t h f i s t u l a occlusion. In one p a t i e n t , t h e reaponae p a t t e r n precluded banding or occlusion of t h e f i s t u l a . I n t h e remainder, the physiologic responses permitted treatment by banding o r occlusion. It aeema a d v i r a b l e t o adequately e v a l u a t e t h e physiologic response p a t t e r n s of p a t i e n t s v i t h h e d y n a m i c a l l y s i g n i f i c a n t arteriovenous f i a t u l a r p r i o r t o d e f i n i t i v e treatment. INTRODUaION
Since the introduction of t h e i n t e r n a l arteriovenous f i s t u l a by
Brescia et. al. i n 1966 ( l ) , it h a r becom tho moat c o m l y ured mode of angioaccars f o r chronic h e d i a l y s i s . cidence of complications occur, including:
A suull, but r i g n i f i c a n t ,
in-
thrombosis, i n f e c t i o n , radial
a r t e r y s t e a l syndrome, aneurysm forrmtion, and i n t r a c t a b l e congestive h e a r t f a i l u r e . (2-8)
In m a t series i n v e s t i g a t i n g h e d y n a m i c a l l y
s i g n i f i c a n t f i a t u l a s , a t y p i c a l reapoose p a t t e r n t o acute o c c l w i o n
665 Copyn#Jtt 0 1977 by Marcel Dekker. lnc. All RUhu Reserved Neither this work nor any part may be reproduced or tnmmitted UI any form Or by any means. electronic or mechanical. including photocopying. microfilmiw. and recording. or by any infornution storye and retneval system. without permision In writin8 from the publrrhn
CERRA ET AL.
666 has been described.
I n general, t h i s response c o n s i s t s of increased
t o t a l p e r i p h e r a l r e s i s t a n c e (TPR) , decreased c a r d i a c output (C.O.), de’creased h e a r t r a t e (HR) and an improvement of 02 consumption (02C) (9,10,11,12). Seven p a t i e n t s with hemodynamically s i g n i f i c a n t f i s t u l a s (as de-
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fined i n m a t e r i a l s and methods) were p h y s i o l o g i c a l l y investigated.
Most
p a t i e n t s demonstrated the c l a s s i c response t o acute manual f i s t u l a occlusion.
The r e m i n i n g p a t i e n t s , however, had v a r i a n t response p a t t e r n s
with s i g n i f i c a n t physiologic a l t e r a t i o n s , some precluding c l o s u r e o r banding of t h e f i s t u l a .
These p a t t e r n s of physiologic response c o n s t i -
t u t e the b a s i s of t h i s report.
MATERIALS AND METHODS From 1970-1976, seven p a t i e n t s presented with r e f r a c t o r y congestive heart failure.
They were p a r t of a 45 p a t i e n t pool undergoing chronic,
s t a b l e hemodialysis during t h e same time period. ranged i n age from 7-68 years old.
The p a t i e n t pool
A l l had i n t e r n a l arteriovenous f i s -
t u l a e f o r angioaccese; about 807. were hypertensive and required a n t i hypertensive medication; about 107. had d i a b e t e s m e l l i t u s ; and approximately 407. had one o r more myocardial i n f a r c t i o n s .
The pool turnover
from t r a n s p l a n t a t i o n , m o r t a l i t y , and new p a t i e n t s admitted w a s 20-309. per year, with an average of 45 p a t i e n t s present i n the pool a t any given time. Out of t h i s chronic pool, seven p a t i e n t s developed p e r s i s t a a t
c l i n i c a l signs and symptoms of congestive h e a r t f a i l u r e .
meters included:
These para-
p e r i p h e r a l edema, pulmonary edema, hepatomegally,
increased h e a r t s i z e
09
chest x-ray, s h o r t n e s s of b r e a t h , e x e r t i o n a l
OCCLUSIVE RESPONSE PATTERNS IN DIALYSIS FISTLhAS dyspnea, and nocturnal dyspnea.
667
A l l of theae p a t i e n t s had been on d i a l y s i s
f o r 15-30 months with t h e same i n t e r n a l arteriovenous f i s t u l a being used f o r angioaccess.
None were d i a b e t i c ; six of seven were hypertensive with
d i a s t o l i c blood pressures regulated t o t h e 90-100 rmaHg range on methyldopa (1000-1500 %/day) and/or apresoline (80-160 mg/day).
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16-62 years old.
T h e i r ages ranged
The 62 year old p a t i e n t w a s not hypertensive and was
t h e only p a t i e n t i n the subgroup with a h i s t o r y of p r i o r myocardial inf a r c t i o n s (2 documented).
Hematocrits ranged 16-222.
Pericardial fluid
was not s i g n i f i c a n t on echocardiography and acute changes were not present A l l a r t e r i a l oxygen tensions were g r e a t e r
on m l t i p l e electrocardiograms. than 65 t o r r .
A l l seven p a t i e n t s were t r e a t e d with f l u i d r e s t r i c t i o n ,
s a l t r e s t r i c t i o n , d i g i t a l i z a t i o n , c o n t r o l of blood pressure, u l t r a f i l t r a t i o n and increased d i a l y s i s (up t o 30-35 $Ws/wk).
These DIcarures
f a i l e d t o a l t e r t h e c l i n i c a l signs and symptoms.
. Became of t h e i r r e f r a c t o r y c a r d i a c f a i l u r e , a l l were hemodynamically studied.
There s t u d i e s were performcd using t h e method of cardiogreen
dye d i l u t i o n multivarient computer a n a l y s i s of physiologic d a t a developed by D r . John H. Siegel. (13,14,15)
The f o l l o v i n g d a t a were obtained before
and a f t e r four minutes of acute mmual occlusion of t h e arteriovenous fistulas: (RAP),
Cardiac output (CO),
s t r o k e volume (SV), right a t r i a l pressure
mixing time (tm, r e f l e c t i n g innate v e n t r i c u l a r c o n t r a c t i l i t y ) ,
h e a r t r a t e (HR), t o t a l p e r i p h e r a l resistance (TPR), mean BP, arteriovenous oxygen s a t u r a t i o n d i f f e r e n c e (A-VOz),
and oxygen consumption (02C).
Each study was repeated t h r e e times. RESUITS
Three d i s t i n a t p a t t e r n s of physiologic response t o acute manual occlusion of the arteriovenous f i s t u l a s were observed.
668
CERRA ET AL.
The most commn p a t t e r n w a s t h a t of an increased TF'R, decreased CO, decreased C I , decreased SV, decreased RAP, and a decreased HR.
In
addition, a l l had a degree of reduction i n myocardial c o n t r a c t i l i t y , a s q u a n t i t a t e d by t h e t m value. seven p a t i e n t s s t u d i e d .
This p a t t e r n was seen i n f i v e of the
An example, labeled response "A"
is seen i n
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Table 1. A second p a t t e r n , response "B", w a s characterized by a l a r g e de-
crease i n TPR, decreased t m . increased SV, increased CO, increased C I , decreased MBP and increased 02C (see Table 1).
This p a t t e r n w a s found
i n one p a t i e n t , a 16 year old black male with advanced hypertensive cardiovascular disease. Response "C" was observed in one p a t i e n t , a 62 year old white male with advanced myocardopathy, primarily of a t h e r o s c l e r o t i c etiology. TABLE 1
PATTERNS OF PHYSIOLOGIC RESPONSE TO A
CO
(Llmin)
CI
(LlminIm2)
SV
(d>
RAP
(dg)
tm
(set)
m
(beats l a i n )
TPR
(dynes-cm x
MBP A-VO2 diff. 02c
(Vol 9.) (Vol 9.)
lo-')
m FISTULA OCCLUSION
open
closed
open
13.61
6.14
6.6
9.3
3.1
2.4
9.79
4.42
4.0
5.6
1.9
1.5
160.1
94.5
60
84.5
38.4
28.3
closed
open
closed
6.2
0
19.0
16.0
11.3
10.0
5.27
7.20
10.0
7.0
18.6
23.2
85
65
110
110
80
as
529
1627
1758
946
1820
2492
90
125
115
110
70
75
2.06
2.32
4.6
4.4
6.6
6.6
143
306
413
202
158
280
OCCLUSIVE RESPONSE PATTERNS I N DIALYSIS FISTULAS
669
This p a t t e r n was c h a r a c t e r i z e d by an i n c r e a s e in an already elevated TPR as w e l l as a decreased COY decreased C I , decreased SV, increased MBP, decreased t m and decreased 02C.
(see Table 1)
Three of t h e type "A" responses were t r e a t e d with f i s t u l a banding (16), r e s u l t i n g i n a marked improvement i n t h e i r c l i n i c a l s t a t u s .
The
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remaining two type "A" p a t i e n t s had t h e i r f i s t u l a s occluded and new f i s t u l a s placed. thereafter.
Both, however, received r e n a l a l l o g r a f t s s h o r t l y
No symptoms or s i g n s have recurred.
also ceased functioning i n 2-3 months.
I n both, t h e f i s t u l a s
The type "B" p a t i e n t had t h e
f i s t u l a banded and has done very w e l l since.
The type "C' response was
t r e a t e d with increased d i a l y s i s , but with l i t t l e change in c l i n i c a l s t a t u s t o present.
DISCUSSION The u s u a l response t o acute f i s t u l a occlusion is c h a r a c t e r i z e d by an increased TW, decreased C0;dccrcased RAP and a decreased SV. This typical p a t t e r n was seen i n f i v e of seven p a t i e n t 8 s t u d i e d with hemodynamically s i g n i f i c a n t arteriovenoua f i s t u l a s . o t h e r responee p a t t e r n s were noted.
In a d d i t i o n , t w o
The second p a t t e r n had a sharp
decrease i n TPR accompanied by an increa8ed COY decreased t m , increa8ed
SV and decreased MBP.
A t h i r d v a r i a n t was Characterized by an elevated
TPR t h a t climbed even higher, a8sociated with a decreased CO, decreased
SV, increased MBP and decreased tm. For many years t h e r e has been much concern about t h e mechanics of arteriovenous f i s t u l a s .
Before the advent of t h e Brascia-Cimino f i s t u l a
f o r angioaccess i n hemodialysis, t h e major i n v e s t i g a t i o n s d e l t with cong e n i t a l and traumatic AV shunts.
(5,9,11,17,18,19,20,21).
In t h i s set-
t i n g , c r e a t i o n of an arteriovenous f i s t u l a provides an inmediate pathway
CERRA ET AL.
670
f o r t h e passage of blood from t h e high r e s i s t a n c e of t h e a r t e r i a l system i n t o t h e low r e s i s t a n c e of t h e venous system.
With the reduction i n TPR,
c a r d i a c output is i n i t i a l l y maintairied by an increase i n h e a r t r a t e . With time t h e r e is an i n c r e a s e i n plasma volume and red c e l l mass and CO i s maintained by an increased s t r o k e volume with a reduction in HR.
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(5).
The dynamics of the system, then, change a s a function of time.
There i s a progressive d i l a t a t i o n of a l l components of the f i s t u l a c i r c u i t , including the h e a r t . (19)
Schenk and a s s o c i a t e s (20) have dernon-
s t r a t e d an increase of up t o 68% of f i s t u l a flow i n one year.
They have
a l s o s t a t e d t h a t t h e f a l l i n CO produced by acute manual occlusion of a chronic AV f i s t u l a i s equal t o the blood flow through t h a t f i s t u l a . Acute occlusion of an AV f i s t u l a has been widely reported t o cause decreased HR (Branham's s i g n ) .
Branham's s i g n has s i n c e been reported
t o be u n r e l i a b l e , occuring i n only 68% of those p a t i e n t s reported by
Nickerson.
(12)
Our d a t a a l s o show a l a c k of c o r r e l a t i o n between acute
f i s t u l a occlusion and decreased HR, as Branham's s i g n was p o s i t i v e in only two of seven p a t i e n t s .
The c r e a t i o n of AV f i s t u l a s i n p a t i e n t s with chronic r e n a l f a i l u r e r e q u i r i n g hemodialysis places an increased physiologic demand on an already compromised cardiovascular system.
These p a t i e n t s a r e often
anemic, hypertensive and on vasoactive antihypertensive medications, overloaded with water and s a l t and frequently have an autonomic neuropathy, d i a b e t e s m e l l i t u s , a t h e r o s c l e r o t i c h e a r t d i s e a s e , o r an i n t r i n s i c myocardopathy.
A l l these f a c t o r s add t o the physiologic demands o f the
entire fistula circuit.
Early c l i n i c a l manifestations of CHF may be noted
even i n asymptomatic p a t i e n t s with arteriovenous f i s t u l a s megaly, gallop rhythm, and abnormal ECG.
-
such as, cardio-
Additional e x e r c i s e in the form
of a c t i v i t i e s of d a i l y l i v i n g may serve t o p o t e n t i a t e the already s t r e s s e d hemodynamic s t a t u s of t h e myocardium.
OCCLUSIVE RESPONSE PATTERNS IN DIALYSIS FISTULAS
671
The p a t i e n t s studied represent a s e l e c t subgroup of p a t i e n t s on chronic hemodialysis i.e.,
those in whom t h e AV f i s t u l a s i g n i f i c a n t l y
contributed to i n t r a c t a b l e c a r d i a c f a i l u r e .
The majority of t h e p a t i e n t s
i n t h e present study with hemdynamically s i g n i f i c a n t f i s t u l a s demons t r a t e d t h e standard type of response p a t t e r n t o acute occlusion, except
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f o r t h e i r c o n t r a c t i l i t y changes.
This type "A" response occurred i n those
p a t i e n t s who were in a t r u e high output c a r d i a c f a i l u r e . F i s t u l a occlusion produced a reduction i n preload (decreased RAP) and an increase i n a f t e r l o a d (increased TPR), with a r e s u l t a n t decrease
02C and increased MBP and A-VO2.
Stroke volume and c o n t r a c t i l i t y decreased
i n a l l p a t i e n t s and probably r e f l e c t s t h e combined e f f e c t s of decreased v e n t r i c u l a r f i l l i n g pressure from reduced venous r e t u r n (decreased RAP), reduced h e a r t volume and increased p e r i p h e r a l r e s i s t a n c e .
These phenomena
a l s o occurred i n t h e two p a t i e n t s i n whom h e a r t rate decreased with f i s t u l a occlusion, i.e.
i.h s p i t e of an increase i n d i a s t o l i c f i l l i n g time.
This
again probably r e f l e c t s t h e i n t e r p l a y of changing preload (RAP) and a f t e r load (TPR) with f i s t u l a occlusion.
The antihypertensive medication
(methyldopa) may a l s o have played some r o l e i n t h e observed parameters. A p a t i e n t with moderate i n t r i n s i c myocardial d i s e a s e (thought t o
be mainly h y p e r t e n d v e in origkn) r e s u l t i n g i n a reduction of coazract i l i t y s t a t u s showed physiologic response W' t o f i s t u l a occlusion. Occlusion produced an increased C.O.
i n the presence of a decrease
of preload (RAP) and a f t e r l o a d (decreased TPR) and an increase of SV. increased C.O.
The
probably r e f l e c t s the increased SV from a decreased TPR
and increased c o n t r a c t i l i t y (decreased tm).
Heart rate d i d not change.
The paradoxic decreased i n TPR has s e v e r a l possible explanations.
It
may have represented t h e presence of some autonomic neuropathy o r an e f f e c t of the antihypertensive medications (methyldopa, hydralazine, clonidine).
The increase i n e f f e c t i v e c i r c u l a t i n g blood volume follow-
672
CERRA ET AL..
ing f i s t u l a occlusion may a l s o have produced a reduction i n the reninangio-tension a c t i v i t y , although t h e r a p i d i t y of the response might r a i s e
some question.
The p a t i e n t s h e a r t s i z e was a l s o q u i t e l a r g e ; decreased
preload from f i s t u l a occlusion may a l s o have s h i f t e d him t o a more favora b l e l o c a t i o n on the S t a r l i n g curve.
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Johnson and Blythe (10) reported e i g h t p a t i e n t s w i t h AV shunts f o r hemodialysis i n whom they s t u d i e d c a r d i a c output before and a f t e r acute occlusion of t h e shunts.
Six of t h e i r p a t i e n t s showed the standard
response; b u t , s i g n i f i c a n t l y , two p a t i e n t s f a i l e d t o demonstrate t h a t pattern.
The authors were unable t o r e l a t e the absence of the standard
p a t t e r n t o t h e type of f i s t u l a ( i n t e r n a l or e x t e r n a l ) or t o i t s s i z e or age.
These p a t i e n t s had i n f a c t shown e i t h e r no change o r a s l i g h t in-
crease i n CO and C I upon manual occlusion of t h e i r AV f i s t u l a f o r 15 minutes.
This increase i n CO upon f i s t u l a occlusion would perhaps
correspond t o out findings i n physiologic rasponse "B".
Unfortunarely,
no other physiologic d a t a w a s available.
Type "C" response w a s found i n a p a t i e n t with severe i n t r i n s i c myocardopathy and a severe reduction i n c o n t r a c t i l i t y . produced a reduction i n preload.
F i s t u l a occlusion
The r a t h e r marked increase i n a f t e r -
load In the presence of t h e severely compromised c o n t r a c t i l i t y , however, served t o p o t e n t i a t e t h e myocardial f a i l u r e .
The primary f a c t o r i n t h i s
response was probably t h e very poor i n t r i n s i c c o n t r a c t i l i t y r e s u l t i n g from the p a t i e n t ' s a t h e r o s c l e r o t i c h e a r t d i s e a s e and p r i o r myocardial infarctions. Many f a c t o r s appear t o influence the p a t t e r n s of response t o acute f i s t u l a occlusion i n chronic hemodialysis p a t i e n t s with hemodynamically s i g n i f i c a n t AV f i s t u l a s .
The major f a c t o r s seem t o be the innate con-
t r a c t i l i t y s t a t u s of the myocardium, the i n t e r p l a y of preload and a f t e r -
OCCLUSIVE RESPONSE PATT.ERNS I N DIALYSIS FISTULAS
673
load a f t e r acute f i s t u l a occlusion, the type of medications being r e ceived, and the presence of autonomic neuropathy.
In a given p a t i e n t
i t is not p o s s i b l e t o accurately p r e d i c t t h e s e f a c t o r s and t h e response
t o f i s t u l a occlusion by c l i n i c a l c r i t e r i a without appropriate physiologic evaluation.
It seems appropriate t o adequately evaluate t h e physiologic
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response p a t t e r n t o acute occlusion i n p a t i e n t s with h e d y n a m i c a l l y s i g n i f i c a n t f i s t u l a s p r i o r t o undertaking a c l i n i c a l course of therapy. REFERENCES
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