الفهرس 
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Abstract
Cardiovascular disease is highly prevalent in those initiating dialysis. Dialysis patients have an excess of cardiovascular mortality. The increased prevalence of cardiovascular disease in CKD-patients is in part explained by the traditional risk factors such as hypertension, diabetes, dyslipidemia and increased age, but also by specific factors, such as calcium-phosphate disturbances with arterial and heart calcification (Provenzano et al., 2019).
Patients with ESRD need long-term vascular access for haemodialysis. An arteriovenous fistula (AVF) is currently considered the gold standard access for hemodialysis, as it has lower risk for infection, lower tendency to thrombotic occlusion, greater blood flow, reduced treatment time and is less expensive to maintain than alternative vascular access methodologies (Soliman et al., 2022).
Permanent catheters are alternative vascular accesses for patients in whom AVF is considered unsuitable for some reason (e.g. exhaustion of vascular bed, previous steal syndrome in functioning AVF, severe hypotension). However, several problems have emerged following wide spread of its use. These include a higher risk of central venous stenosis, an increased morbidity for infection or catheter thrombosis, with decreased dialysis adequacy due to lower blood flow rates (Soliman et al., 2022).
The presence of an AVF has a significant haemodynamic impact on the hemodynamic and circulatory parameters of the cardiovascular system. The current literature suggests that the creation of AV access can cause or exacerbate heart failure (HF), LVH, pulmonary hypertension, coronary artery disease, and valvular dysfunction (Deyranlou et al., 2021).
The mechanism underlying this haemodynamic effect is based on shunting blood from a high-pressure artery via the AVF to a low-pressure vein, thus bypassing capillary beds and decreasing systemic vascular resistance (SVR). These haemodynamic changes stimulate a compensatory increase in heart rate, stroke volume and total plasma volume (Bardelli et al., 2020).
The elevation in cardiac output (CO) associated with AVF depends upon the size of the shunt and the magnitude of the resultant reduction in SVR. Because blood flowing through the shunt bypasses the capillary circulation, the total CO increases by the quantity of blood flowing through the shunt to maintain capillary perfusion (Soliman et al., 2022).
Echocardiography is used to estimate the risk for cardiovascular complications in patients with end-stage renal. It is widely available and recommended in patients with end-stage renal disease for diagnosis, guidance of treatment, and pretransplantation evaluation.
The presence of an AVF has a significant hemodynamic impact on the hemodynamic and cardiac parameters of the heart. The current literature suggests that the creation of AV access can cause or exacerbate heart failure (HF), LVH, pulmonary hypertension, and coronary artery disease, but in our study in compare with patients with permanent catheter there was no significant difference in cardiac parameters. In the other hand patients with AVF show improvement in other labs especially hemoglobin, Iron profile, Kt/v and URR, so there is no problem to create AVF in patients with heart failure EF 35-50%.
Aim of study
The aim of the present study was to evaluate effect of arteriovenous fistula versus permanent catheter on cardiac parameters in prevalent hemodialysis patients with heart failure and its relation to short term dialysis outcome and mortality.
Patient and method
This was a prospective study, was conducted in Ain-Shams University hemodialysis unit on 60 patients divided into 2 equal groups (group A): 30 ESRD patients with heart failure with distal AV fistula, (group B): 30 ESRD patients with heart failure with permanent catheter insertion. All patients were assessed by echocardiography cardiac changes at the beginning of the study and after 6 months with follow up short term dialysis complication and mortality.
Result:
• Patients with AVF had longer time of dialysis session, dialysis duration, more stable blood pressure compared with patients with permanent catheter with significant p value <0.001, <0.001, 0.012, 0.010, 0.001 respectively.
• WBC count and ferritin higher in patients with catheter versus patients with AVF P Value (0.001, 0.006) while lower Na, URR and KT/v pvalue (0.045, <0.001, <0.001) respectively.
• There was no significant difference in ECHO parameters between two groups.
• patients with AVF showed significant improvement after 6 months as regard Hb TSAT, KT/v, URR, and increase in LAD versus patient with permanent catheter mean p value0.001,<0.001,<0.001,0.013, while no significant difference as regard other ECHO parameters (pulmonary. hypertension, RAD, LVEDD) p value>0.05.
• patient with permanent catheter show deterioration of TAST, s.albumin, URR, kt/v in Hb, EF, LAD, RAD, LVEDD after 6 months of follow up with p value (<0.001, <0.001, 0.014, 0.010, 0.012, <0.001, 0.002, 0.001, <0.001) respectively
• Patient with permanent catheter show deterioration of Hb, WBC, ferritin, TAST, albumin, different, EF patients compared with patients with AVF with significant difference p value (<0.001) respectively, while no significant difference in other ECHO parameters(LAD, RAD, LVEDD, pulmonary hypertension) between two groups p value >0.05.
• Permanent catheter cause risk 10 times than AVF to have lower EF.
• EF had positive correlation with Na and negative correlation with pump flow, p value (0.040, 0.020), LAD has negative correlation with Ca p value 0.044, RAD has positive correlation with age and pump p value (0.001, 0.050),.in patient with AVF at the beginning of study.
• In patients with AVF after 6months EF has positive correlation URR, p value (0.028) And RAD has negative correlation with dialysis duration p value (0.022).
• RAD has negative correlation with WBC and po4 p value (0.009, 0.004), negative correlation between EF and k p value 0.004 in patient with permanent catheter at the beginning of the study.
• EF has negative correlation with po4 and k p value (0.01, 0.048) in patients with permanent catheter after 6 months.
So AVF is a good access in heart failure patients compared to permanent catheter.