Vascular Access-Related Heart Failure: Pathophysiological Insights, Diagnostic Challenges, and Management Strategies.

Arteriovenous access-related heart failure (ARHF) is a critical yet underrecognized complication in ESKD patients on hemodialysis. Heart failure is highly prevalent among patients with ESKD and is often characterized as uremic cardiomyopathy. In this setting, the increased hemodynamic load imposed by a functioning hemodialysis access circuit can further aggravate the underlying myocardial pathology, potentially precipitating high-output heart failure. Vascular access accounts for 23% of high-output heart failure cases, carrying a 58% five-year mortality rate. Despite its prevalence, ARHF remains underdiagnosed and mismanaged due to a lack of established societal guidelines. This narrative review aims to delineate the complex pathophysiology of ARHF, highlight current diagnostic challenges, identify existing gaps in evidence, and suggest potential methods to enhance its management. Hemodynamic changes are investigated, including increased cardiac output, cardiac remodeling, pulmonary hypertension, and arterial stiffening, alongside non-hemodynamic factors. Diagnostic modalities, including history and physical exam, laboratory cardiac biomarkers, transthoracic echocardiography, vascular duplex ultrasound, magnetic resonance imaging and right heart catheterization are discussed. Management strategies, encompassing preoperative prevention and risk stratification, medical therapies, surgical interventions (e.g., banding), and surveillance protocols, are also outlined. This comprehensive review addresses current evidence gaps and provides clinical guidance to improve ARHF recognition, diagnosis, and management.