Abstract: PUB076
Multiorgan Point-of-Care Ultrasound-Guided Diagnosis and Management of High-Flow Arteriovenous Fistula (AVF)-Related Pulmonary Hypertension
Session Information
Category: Dialysis
- 803 Dialysis: Vascular Access
Authors
- Kim, Eunjung, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, Gyeonggi-do, Korea (the Republic of)
- Lee, Sua, Hallym University, Chuncheon-si, Gangwon-do, Korea (the Republic of)
- Choi, Gwangho, Hallym University, Chuncheon-si, Gangwon-do, Korea (the Republic of)
- Kim, Do Hyoung, Hallym University, Chuncheon-si, Gangwon-do, Korea (the Republic of)
Introduction
Multi-organ point-of-care ultrasound (POCUS) can provide an integrated bedside assessment of pulmonary and venous congestion, cardiac filling pressures, and access-related flow burden.
Case Description
A 58-year-old man with diabetic end-stage renal disease on maintenance hemodialysis since 2019 was referred for worsening pulmonary hypertension. He had a left brachiocephalic AVF created in 2019 and a right brachiocephalic AVF created in 2021 due to recurrent thrombosis, resulting in functioning AVFs in both arms. Access flow assessment showed brachial artery flow rates of 450 mL/min in the left AVF and 920 mL/min in the right AVF. Multi-organ POCUS demonstrated bilateral multiple B-lines with pleural effusions, an inferior vena cava diameter of 2.3 cm with reduced collapsibility, portal vein pulsatility fraction >50%, and hepatic vein systolic flow reversal, indicating significant venous congestion. Focused cardiac ultrasound showed biatrial enlargement, mitral regurgitation, E/e′ of 23.5, and tricuspid regurgitation with a TRVmax of 4.6 m/s, corresponding to an estimated right ventricular systolic pressure >60 mmHg and severe pulmonary hypertension. Cardiac output was estimated at 2.99 L/min, while total access flow was approximately 1,370 mL/min, resulting in Qa/CO >0.3 and suggesting high-flow AVF–related hemodynamic burden. The patient underwent AVF ligation and aggressive volume optimization, including bilateral pleural drainage and removal of 7 kg of fluid. Follow-up POCUS demonstrated improvement in venous congestion, normalization of the portal vein waveform, improvement of hepatic vein Doppler pattern, reduction of TRVmax to 2.8 m/s, and decrease in E/e′ to 15, indicating improvement in pulmonary hypertension.
Discussion
This case highlights that multi-organ POCUS is not simply a tool for confirming volume overload, but an integrated physiologic assessment that can identify venous congestion and high-flow AVF–related hemodynamic burden, guide therapeutic decisions such as AVF ligation and volume optimization, and provide real-time evidence of hemodynamic improvement in patients with pulmonary hypertension.