A hemodialysis patient with a history of CABG (coronary artery bypass graft) operation visited my center for arteriovenous access creation.
This patient had undergone multiple AV access placements on his right arm. When I examined the current AV graft of his right upper arm, it was found to end its longevity, and no more AV access placement was feasible on his right arm. In contrast, he had never had vascular access surgery on his left arm because his physician emphasized that any AV access should not be placed on his left arm to avoid coronary steal syndrome. In fact, the patient underwent CABG using the left internal thoracic artery. I'd like to recommend a new AV access creation in the left arm, but the patient is afraid that he will die of AMI if he gets AV access in his left arm. So, I'm here to ask you for advice.
First,
Would it lead to coronary steal syndrome if I created an AVF or AVG on his left arm? How high is the probability for the patient to encounter a coronary steal in such a case?
Second,
If an AVF creation was planned in the left arm, would limiting blood flow, for example, to 600-800ml/min or less help to reduce the risk of coronary steal?
Third,
When a patient with a CABG history needs an AV access creation, should we always confirm which graft for CABG was used and which way of CABG operation was performed?
I'd like to appreciate your comments.
Hyungseok Lee, MD, FASDIN
Hallym University Sacred Heart Hospital, South Korea.
pcsacred@gmail.com
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Posted Friday, April 8, 2022
In our experience, we have never limited right or left arm access options due to CABG. But we have not actively followed outcomes here either.
There is limited data available in several small studies [The first 2 articles below are from JVA, and you should be able to access them with ASDIN membership.]
A paper from Korea showed that 3/25 patients developed clinical cardiac symptoms that were attributed to coronary steal (without angiographic data), while another 23-patient retrospective study from Israel showed no significant issues. A 3rd larger study with 155 patients in Japan showed no significant issues with ipsilateral or contra-lateral access. There are other studies that show some conflicting data.
My own gut feeling is that it doesn’t really make a clinical difference – especially if the patient has a good ejection fraction.
However, limiting blood flow in a new access would be reasonable consideration – and we are beginning to appreciate the value of lower blood flows more and more in our patient population.
If your patient and referring physicians are concerned, it may be reasonable to consider a fistula with eventual flow reduction. Assuming the patient is not a PD candidate, the alternatives would be the risk of catheter dependence or a femoral graft – which may be more problematic than any risk of coronary steal.
1. https://journals.sagepub.com/doi/pdf/10.5301/jva.5000693
2. https://journals.sagepub.com/doi/pdf/10.5301/jva.5000690
3. https://pubmed.ncbi.nlm.nih.gov/23402689/#:~:text=Conclusions%3A%20Revascularization%20of%20the%20LAD,isolated%20CABG%20in%20dialysis%20patients.