**11. Cardiovascular consequences of AVF**

Sometimes very-high-flow AVFs can lead to VH, progressive aneurysmal dilatation of vein with skin ulceration, hemodialysis access-induced distal ischemia, and high-output heart failure with or without pulmonary hypertension. AVFs have effects on cardiac functions related to the increase in preload and cardiac output (CO). It is difficult to define cardiovascular consequences due to AVF in a precise manner. This is due to the fact that patients requiring long-term hemodialysis tend to have volume overload due to water and salt retention. There could also be pressure load due to arterial sclerosis and hypertension and increased CO secondary to chronic anemia. In addition, many hemodialysis patients have significant pre-existing myocardial, valvular, or coronary heart disease, as the vascular calcification due to CKD-MBD (chronic kidney disease—mineral and bone disorder). Congestive heart failure (CHF) is highly prevalent among patients with ESRD. Approximately 35–40% of patients with ESRD have an established CHF diagnosis at initiation of hemodialysis. Worsening in cardiac functions soon after AVF creation has also been observed favoring a causative effect of the AVF on certain cardiac functions [24].
