title: Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula.
abstract: BACKGROUND
  In patients in chronic hemodialysis via upper extremity arteriovenous fistula in whom ipsilateral internal thoracic artery graft was used for myocardial revascularization, hemodynamic interference between the fistula and the graft during dialysis can be hypothesized.
  
  
  RESULTS
  In 5 patients undergoing chronic hemodialysis via upper extremity arteriovenous fistula, ipsilateral to an internal thoracic to left anterior descending graft mammary flow was studied by means of transthoracic echo-color Doppler at baseline and during hemodialysis. Flow in the contralateral mammary artery was used as control. Transthoracic echocardiography was performed in concomitance with flow evaluation to assess eventual modifications of left ventricular segmental wall motion. Immediately after hemodialysis pump start there was a marked reduction of peak systolic and end-diastolic velocities and time average mean velocity and flow in the ITA ipsilateral to the fistula, whereas no substantial hemodynamic modification was evident in the contralateral artery. Dialysis-induced reduction of ipsilateral ITA flow was accompanied by evidence of hypokinesia of the anterior left ventricular wall. Three cases also experienced clinical angina.
  
  
  CONCLUSIONS
  Hemodynamically evident flow steal and consequent myocardial ischemia develop during hemodialysis in patients with upper extremity arteriovenous fistula and ipsilateral internal thoracic artery to coronary graft. These data have major implications for patients' management, both for nephrologists and cardiac surgeons.
authors.affiliation: Department of Cardiac Surgery, Catholic University, Rome, Italy. mgaudino@tiscali.it
authors.forename: Mario
authors.initials: M
authors.lastname: Gaudino
authors.forename: Michele
authors.initials: M
authors.lastname: Serricchio
authors.forename: Nicola
authors.initials: N
authors.lastname: Luciani
authors.forename: Stefania
authors.initials: S
authors.lastname: Giungi
authors.forename: Andrea
authors.initials: A
authors.lastname: Salica
authors.forename: Roberto
authors.initials: R
authors.lastname: Pola
authors.forename: Paolo
authors.initials: P
authors.lastname: Pola
authors.forename: Giovanna
authors.initials: G
authors.lastname: Luciani
authors.forename: Gianfederico
authors.initials: G
authors.lastname: Possati
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D002908:Chronic Disease; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D003324:Coronary Artery Disease / Q000601:surgery; D018618:Echocardiography, Doppler, Color; D006439:Hemodynamics; D006801:Humans; D008323:Mammary Arteries / Q000000981:diagnostic imaging / Q000637:transplantation*; D017202:Myocardial Ischemia / Q000209:etiology*; D006435:Renal Dialysis / Q000009:adverse effects*; D051437:Renal Insufficiency / Q000628:therapy; D034941:Upper Extremity / Q000098:blood supply