Creating a vascular access in the presence of a cardiovascular implantable electronic device (CIED) in a patient with or approaching end-stage renal disease can be challenging. In this study, we aimed to evaluate the impact of a CIED on the outcomes of vascular access creation in hemodialysis patients and determine their effects on vascular access patency. This is a single-center retrospective review of hemodialysis patients who underwent vascular access creation after CIED placement. Outcomes of vascular access creation and need for endovascular interventions were compared between patients with vascular access created ipsilateral and contralateral to the site of CIED. Comparing patients with arteriovenous (AV) access created ipsilateral to CIED placement (n=19) versus the contralateral side (n=17), the primary failure rate was 78.9% versus 35.3% (p=0.02). For AV accesses that were matured, the median primary patency durations for AV accesses created ipsilateral to the CIED was 11.2 months compared to 7.8 months for AV accesses created contralateral to the CIED (p=1.00). AV accesses created ipsilateral to a CIED have a higher primary failure rate compared with the contralateral arm and should be avoided as much as possible.

Background Patients with cirrhosis and refractory ascites have physiologic and hormonal dysregulation that contributes to decreased kidney function. Placement of a transjugular intrahepatic portosystemic shunt (TIPS) can reverse these changes and potentially improve kidney function. We sought to evaluate change in estimated glomerular filtration rate (eGFR) following TIPS. Study Design Retrospective, matched cohort analysis. Settings & Participants Patients who underwent first-time TIPS placement for refractory ascites in 1995–2014. Frequency matching was used to generate a comparator group of patients with cirrhosis and ascites treated with serial large-volume paracentesis (LVP) in a 1:1 fashion. Predictor TIPS placement compared to serial LVP. Outcome Change in eGFR over 90 days’ follow-up. Measurements Multivariable regression stratified by baseline eGFR <60 vs. ≥60 mL/min/1.73 m2; analysis of effect modification between TIPS placement and baseline eGFR. Results 276 subjects (TIPS, n=138; serial LVP, n=138) were analyzed. After 90 days, eGFR increased significantly after TIPS placement in subjects with baseline eGFR <60 mL/min/1.73 m2 compared to treatment with serial LVP (21 [95% CI, 13–29] mL/min/1.73 m2; p <0.001) and was no different in those with eGFR ≥60 mL/min/1.73 m2 (1 [−9 to 12] mL/min/1.73 m2; p = 0.8). There was significant effect modification between TIPS status and baseline eGFR (p = 0.001) in a model that included all subjects. Limitations Outcomes restricted by clinically recorded data; clinically important differences may still exist between TIPS and LVP cohorts despite good statistical matching. Conclusions TIPS placement was associated with a significant improvement in kidney function. This was most prominent in subjects with baseline eGFR <60 mL/min/1.73 m2. Prospective studies of TIPS in populations with eGFR <60 mL/min/1.73 m2 are needed to evaluate these findings.

Despite the Fistula First Initiative recommendations, grafts need not be discounted as a first-line hemodialysis access option in select elderly patients.