Early echocardiographic modifications after flow reduction by proximal radial artery ligation in patients with high-output heart failure due to high-flow forearm arteriovenous fistula

J Vasc Access. 2020 Sep;21(5):753-759. doi: 10.1177/1129729820907249. Epub 2020 Feb 27.


Background: Arteriovenous fistula (AVF) for haemodialysis (HD) induces a volume/pressure overload which impairs bi-ventricular function and increases systolic pulmonary arterial pressure (PAPS) and left ventricular mass (LVM). In the presence of high blood flow (Qa) AVF (> 1.5 L/min/1.73 m2) and cardio-pulmonary recirculation (>20%), high-output congestive heart failure (CHF) may occur and AVF flow reduction is recommended. Proximal Radial Artery Ligation (PRAL) is an effective technique for distal radio-cephalic (RC) AVF flow reduction.

Methods: we evaluated six HD and four transplant patients with high-flow RC AVF and symptoms of CHF who underwent PRAL. We compared echocardiographic (ECHO) findings before (T0) and 1 and 6 months (T1,T6) after PRAL. Preoperative ECHO was performed before (T0b) and after AVF anastomosis manual compression (T0c).

Results: At T1 AVF flow reduction rate was 58.4% ± 13% and 80% of patients reported improved CHF symptoms. ECHO data showed an improvement of tricuspid annular plane systolic excursion (TAPSE) at T1 (p = 0.03) and a reduction of PAPS at T6 (p = 0.04). TAPSE improved after AVF anastomosis compression during preoperative ECHO (p = 0.03). Delta of TAPSE at the dynamic manoeuvre at T0 directly correlated with early (1 month after PRAL, p = 0.01) and late (6 months after PRAL, p = 0.04) deltas of TAPSE.

Conclusions: AVF flow reduction after PRAL induces immediate regression of CHF symptoms, early improvement of TAPSE and late improvement of PAPS, suggesting a prevalent right sections involvement in CHF. Preoperative TAPSE modification after AVF anastomosis compression could represent a useful evaluation tool to determine which patients would benefit of PRAL.

Keywords: Arteriovenous fistula; PRAL; TAPSE; cardiovascular; haemodialysis; high flow.

MeSH terms

  • Aged
  • Arteriovenous Shunt, Surgical / adverse effects*
  • Blood Flow Velocity
  • Cardiac Output, High / diagnostic imaging
  • Cardiac Output, High / etiology
  • Cardiac Output, High / physiopathology
  • Cardiac Output, High / surgery*
  • Echocardiography, Doppler, Color*
  • Female
  • Forearm / blood supply*
  • Heart Failure / diagnostic imaging
  • Heart Failure / etiology
  • Heart Failure / physiopathology
  • Heart Failure / surgery*
  • Hemodynamics*
  • Humans
  • Kidney Transplantation
  • Ligation
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Prospective Studies
  • Radial Artery / diagnostic imaging
  • Radial Artery / physiopathology
  • Radial Artery / surgery*
  • Recovery of Function
  • Renal Dialysis*
  • Risk Factors
  • Time Factors
  • Treatment Outcome