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High-Output Cardiac Failure Fistula Banding — ESENeph MCQ

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HardHaemodialysisHigh-Output Cardiac Failure Fistula BandingESENeph

A 72-year-old man on haemodialysis via a left brachiocephalic fistula develops high-output cardiac failure. Echocardiogram shows left ventricular dilatation with ejection fraction 42% and high cardiac output (8 L/min). Fistula flow rate measured by Doppler is 2.8 L/min. What is the most appropriate management?

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Correct answer: B — Banding or flow reduction of the arteriovenous fistula

A fistula flow rate >1.5-2 L/min is associated with high-output cardiac failure. The excessive shunt volume creates a persistently elevated cardiac output, leading to LV dilatation, eccentric hypertrophy, and eventually systolic dysfunction. Fistula banding (surgical narrowing) reduces flow while preserving the access. The target is to reduce flow to 600-1200 mL/min while maintaining adequate dialysis delivery. Complete fistula ligation should be avoided if possible as it eliminates the access. Fistula flow is the most modifiable contributor — addressing this can improve cardiac function significantly.

Reference: MacRae et al 2006 – High-Flow AVF Cardiac Effects; UKKA 2020 – Vascular Access Guidelines