The use of arteriovenous fistula for cancer chemotherapy administration in hemodialysis patients

Introduction

Vascular access is a cornerstone in the management of patients with end-stage kidney disease (ESKD) undergoing chronic hemodialysis (HD). The creation and maintenance of a reliable vascular access are critical determinants for dialysis adequacy, patient survival, and quality of life. Among available access options, the autogenous arteriovenous fistula (AVF) is preferred due to its lower rates of infection and thrombosis, superior patency, and longer functional lifespan compared with arteriovenous grafts (AVG) or central venous catheters (CVCs). ¹ In patients receiving chronic HD, vascular capital preservation is a fundamental principle of long-term management. Each venipuncture, catheter insertion, or vascular intervention carries a risk of thrombosis, stenosis, or central vein occlusion, which may preclude future AVF or AVG creation, limit options for subsequent hemodialysis access and adversely affect patient morbidity and mortality. ²

Patients with ESKD undergoing chronic HD exhibit an increased incidence of malignancy and higher cancer-related mortality, a phenomenon attributed to advanced age, impaired immune surveillance, chronic inflammation and accumulation of carcinogenic toxins. ³ Oncologic treatment frequently comprises intravenous chemotherapy, which requires dedicated vascular access for administration, either through peripheral venous access devices or central venous access devices (CVAD), including peripherally inserted central catheters, tunneled CVCs, or totally implantable venous access ports. ⁴ Although CVADs are often the preferred option, they are traditionally associated with significant complications, particularly catheter-related venous thrombosis and infection, both of which may potentially compromise oncologic treatment. ⁵ The choice of vascular access is primarily determined by the type and duration of chemotherapy, anatomic considerations, and patient preference. Appropriate selection is crucial to optimize treatment efficacy, minimize complications, and enhance patient safety and comfort. ⁴

In patients undergoing HD, cumulative injury to peripheral and central veins resulting from repeated intravenous therapies with cytotoxic agents is of particular concern. ² Accordingly, strategies aimed at minimizing additional venous damage, including the avoidance of peripherally inserted catheters and unnecessary venipunctures, are essential to preserve vascular integrity and to prospect a long-term sustainable dialysis access. ¹

Administration of chemotherapy through a pre-existing AVF may represent a viable alternative for delivering cytotoxic therapy without further compromising the venous system. Herein, we report two cases in which chemotherapy was administered via AVF in HD-dependent oncologic patients.

Case description

Discussion

The use of arteriovenous fistulas and grafts for chemotherapy administration is not a novel concept. Several reports from the 1970s and 1980s described the use of surgically created arteriovenous access, including native AVFs and prosthetic grafts, as a possible mean for repeated chemotherapy delivery in oncologic patients, particularly in those with poor peripheral veins or requiring prolonged treatment courses.^{6 –9} These studies demonstrated that arteriovenous access created specifically for chemotherapy administration, particularly AVFs, could provide durable, safe and convenient venous access.^8,9 More recently, this approach has been considered for patients with central venous access failure, such as superior vena cava thrombosis, or in those with a history of thrombotic events precluding implantation of a venous access port. ¹⁰

In contrast, in the subgroup of hemodialysis patients, only limited evidence is available, including a small series reporting three successful cases of chemotherapy administration via a pre-existing mature AVF, with no major complications; however, long-term vascular access outcomes were not evaluated. ¹¹ Additionally, a retrospective observational cohort study of 84 patients with comorbid cancer prior to AV access placement for HD demonstrated comparable AVF patency rates between patients with and without malignancy, although chemotherapy administration via AVF was not assessed. ¹² Overall, evidence regarding chemotherapy delivery through AVFs in HD patients and its impact on vascular access outcomes remains scarce.

Case 1 illustrates the administration, through a mature AVF, of multiple cycles of chemotherapy consisting of epirubicin and paclitaxel, agents with known vesicant potential. ¹³ The absence of adverse local reactions supports the feasibility of this approach when the AVF is well-developed, puncture technique is precise, and infusion protocols ensure secure cannula fixation. Furthermore, the high-flow hemodynamics of AVFs may mitigate local endothelial toxicity by facilitating rapid drug dilution and limiting contact time with the vessel wall and, thereby, minimizing the risk of potential irritant effects of the chemotherapeutic agents. Although AVF stenosis with partial thrombosis occurred during follow-up, this complication arose approximately 3 years after completion of chemotherapy and an increased risk of thrombosis has not been associated with the chemotherapy agents administered in this patient. ¹⁴ We therefore hypothesize that repetitive cannulation inherent to long-term HD rather than a direct cytotoxic effect was the more plausible contributing factor.

Case 2 highlights a complex clinical scenario involving an elderly patient with multiple comorbidities, incident in chronic HD, and a relapsing malignancy requiring palliative chemotherapy. In this context the chemotherapy administration via existing AVF was favored over placement of a new CVC or implantable port, in consideration of limited life expectancy and the aim to avoid unnecessary invasive procedures and to prioritize a patient-centered approach focused on comfort, dignity, and treatment simplicity. This also demonstrates that AVF-based chemotherapy is technically feasible even in patients with advanced systemic disease without compromising dialysis adequacy or vascular access function. The main limitation in this case is the short follow-up period, only 1 month, attributable to a premature cancer-related death.

In both cases, chemotherapy was administered through the AVF using a 20-gauge peripheral catheter by experienced dialysis nursing staff on non-dialysis days. No local or systemic complications were observed, dialysis adequacy remained stable, and AVF flow rates were preserved. The decision to use an AVF for chemotherapy administration should therefore be individualized and based on a multidisciplinary discussion involving the attending nephrologist, the attending oncologist, and the nursing staff, with additional input from clinicians of other specialities, such as vascular surgery or radiology, when appropriate. We advocate that this strategy may be considered particularly when alternative venous access options are limited, when use of CVAD carries substantial risk or when preservation of future vascular access is a priority. Essential prerequisites include: (1) informed patient consent; (2) attending nephrologist and oncologist agreement; (3) a well-matured and stable AVF; (4) administration by nursing staff with meticulous training and long-term experience with AVF cannulation; (5) appropriate scheduling to allow post-infusion monitoring and coordination with hemodialysis sessions, including administration on non-dialysis days or carefully timed infusion several hours before the start of dialysis or immediately after completion of the session, according to our experience and a previous report. ¹¹ In both reported cases, these conditions were fulfilled, likely contributing to the absence of complications.

Despite the potential advantages of this approach, several limitations and risks should be considered. Arteriovenous fistulas are inherently prone to complications such as thrombosis, stenosis, infection, steal syndrome and high-output heart failure. ¹ The additional use of AVFs for chemotherapy administration may theoretically increase cumulative vascular trauma. Furthermore, certain chemotherapeutic agents, such as anthracyclines and taxanes, are known to cause endothelial irritation and local tissue injury, raising concerns about possible vascular damage when administered through AVFs. ¹³ In addition, patients with cancer, particularly those receiving chemotherapy, are known to have an increased risk of thrombosis, which may further contribute to vascular access complications. ¹⁵ However, available evidence specifically addressing chemotherapy delivery via AVFs remains limited. Early studies in non-dialysis oncology populations reported acceptable safety profiles without a clear increase in thrombotic complications attributable to chemotherapy itself, although these studies lacked long-term vascular follow-up.^8,9 While AVF-based chemotherapy appears feasible in selected patients, its impact on long-term vascular access patency remains undetermined and warrants further investigation.

In conclusion, these cases suggest that chemotherapy administration via an existing AVF may represent a feasible and vein-preserving option in carefully selected HD patients, without compromising vascular access outcomes. We hope this report encourages a more informed multidisciplinary discussion regarding vascular access strategies when the requirements of HD and chemotherapy coexist. Further prospective studies are needed to better define patient selection criteria based on a comprehensive risk-benefit assessment and to better establish the efficacy and safety inherent to this approach.