Cardiovascular Implantable Electronic Devices and Dialysis Access

Patients with end-stage kidney disease have a high incidence of cardiac problems requiring treatment with a pacemaker and/or implantable cardioverter-defibrillator. These devices have typically utilized transvenous leads inserted via axillary or subclavian vein, with resulting risk for central vein stenosis. Arteriovenous access for hemodialysis results in high flow venous return which can result in symptomatic venous hypertension in the setting of ipsilateral central vein stenosis. There are numerous factors that affect selection of cardiac rhythm device therapy and what route of implantation to utilize. Cardiac electrophysiologists must be cognizant of arteriovenous access considerations related to their device therapy. Vascular access surgeons need to be similarly cognizant of cardiac rhythm device considerations related to creation of arteriovenous access. Members of the dialysis patient care team should understand the indications, limitations, and treatment options for cardiac device therapy in order to assure optimal decision-making about device therapy and arteriovenous access. Communication between all involved clinicians is essential, and must include the patient to ensure that he or she is fully informed of treatment alternatives, risks, and benefits. In this chapter, we review the clinical science of cardiac device therapy as it pertains to patients with chronic kidney disease or end-stage kidney disease receiving dialysis, and implications for arteriovenous hemodialysis access. We offer a strategy to optimize outcomes and minimize morbidity associated with cardiac device therapy and arteriovenous access.