HIGH-OUTPUT RIGHT HEART FAILURE FROM EXCESS AVF FLOW: SURGICAL MANAGEMENT VIA DISTALISATION JINGWEN.ONG@MOHH.COM.SG

PE059

HIGH-OUTPUT RIGHT HEART FAILURE FROM EXCESS AVF FLOW: SURGICAL MANAGEMENT VIA DISTALISATION

4

Singapore

Poster Exhibition only

High-flow arteriovenous fistulas (AVFs), defined as a volume flow of >1500mls/min or >20% of cardiac output, may result in significant haemodynamic complications, including high-output cardiac failure and pulmonary hypertension. Recognition of this uncommon but serious condition is essential for timely intervention.

We present the case of a 47-year-old woman with ischaemic heart disease and end-stage renal disease who developed orthopnoea and exertional dyspnoea in December 2024. She had a left brachiocephalic AVF created in 2015, with multiple prior fistuloplasties and stenting. Workup revealed pulmonary congestion on CXR, elevated proBNP (3039pg/ml), and pulmonary artery systolic pressure (PASP) of 60mmHg. Despite successful percutaneous coronary intervention to the right coronary and left anterior descending arteries, symptoms persisted. Notably, symptoms coincided with a fistuloplasty performed in December 2024, whereby an 8mm Covera stent was deployed for juxta-anastomotic stenosis. Post-procedure duplex ultrasound showed elevated brachial artery volume flow (2265mls/min, previously 1235mls/min), and dialysis access flow of 3480mls/min. Repeat echocardiogram demonstrated severe tricuspid regurgitation and worsening pulmonary hypertension (PASP 72mmHg), consistent with high-output right-sided cardiac failure from a high-flow AVF.

Surgical distalisation was planned to reduce flow, but an abscess developed over the juxta-anastomotic site with partial stent exposure. Incision and drainage with staged stent explantation and distalisation using the proximal radial artery and native forearm cephalic vein were performed. Recovery was uneventful apart from minor wound dehiscence managed conservatively.

This case highlights the haemodynamic burden of high-flow AVFs. Early recognition and timely surgical flow reduction are critical to prevent cardiac decompensation while preserving dialysis access.