•Jordan, Yemini, Papageorge

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Body:

Immediate Profound Bradycardia During Arterio-venous Fistula Ligation in a Kidney Transplant Recipient: A Case Report and Literature Review
Background: Arteriovenous fistula (AVF) remains the preferred option for hemodialysis access in patients with end stage renal disease (ESRD). Nevertheless, in a kidney transplant (KT) recipient an AVF can cause a pathological cardiovascular remodeling and should be evaluated for ligation in the setting of functional graft. To our knowledge, there is scarce data regarding the risk of immediate bradycardia during AVF ligation (known as the Nicoladoni-Branham sign), and a proposed operative approach.
Objective: The aim of this report is to describe a case of profound bradycardia and hypertension during AV fistula ligation, and provide a proposed approach for pre- and intra-operative care.
Methods: Herein, in this report we describe the case of a 51-year-old female with a history of ESRD secondary to hypertension who is status post deceased donor kidney transplant and underwent ligation of a large, aneurysmal right brachio-cephalic AVF. During the procedure, clamping of the fistula proximal to the anastomosis resulted in profound bradycardia. A few adjustments were taken in order to complete the ligation of the AV fistula in a safe manner: change in anesthesia approach, modified monitoring considerations, and slower clamping process to decrease hemodynamic instability.
Conclusion: Patients with large aneurysmal fistula are at higher risk for hemodynamic changes during AVF ligation, including bradycardia and hypertension known as Nicoladoni-Branham sign. A special attention should be directed to anesthesia approach and surgical technique to avoid hemodynamic instability.

Relevant history:

51 yo F w/ ESRD s/p kidney transplant presenting for ligation of large, aneurysmal AV fistula. No known cardiac history and prior echocardiogram was normal.

Relevant test results:

Teaching points:

Ligation of a high output AVF can cause a profound hemodynamic response in the patient. Prior to ligation discussion should be had with the anesthesia team to prevent the use of drugs that can compound the effect, ex. dexmedetomidine and bradycardia. Additionally slow ligation of the fistula with appropriate cardiac monitoring should be used to ensure the patient remains stable.