Open peripheral vascular op, severe CM and ESRD

Gabrielle Morris

57yo lady for femoral loop AV graft to provide vascular access for haemodialysis

Background:

  • ESRD on HD
    • 2nd to DM. 
    • Was considered for tplt but workup revealed unoptimised cardiomyopathy
    • Multiple attempts at AV grafting in her right arm, not suitable for graft on the other side due to previous axillary dissection for breast Ca. Currently dialysed via permacath.
  • DCM – EF 25% – due to IHD (LAD disease, unable to be grafted or stented), chemotherapy toxicity and uraemia.
  • Mild asthma – spiro unexpectedly poor in clinic – FEV1 45% predicted, incongruous with symptoms
  • Low ex tol secondary to PVD – claudication 500m (DASI 5.8METS – ? accurate)

Issues:

  • Patient concern about surgical risks (vascular complications, loss of limb)
    • ? non-surgical options such as transition to PD
    • ? duration of time can use permacath
  • Cardiomyopathy
    • Increased CO from graft, ? ability to tolerate with EF 25% and known IHD
    • ? optimized from cardiac perspective – not on Entresto, ? could have bivent PPM

Plan:

  • Complex situation needing MDT input – cardiologist, nephrologist and surgeon