Delayed Arteriovenous Fistula Maturation Associated With an Ipsilateral Transvenous Implantable Cardioverter Defibrillator (ICD) Lead and Suspected Functional Hemodynamic Obstruction.

Arteriovenous fistula (AVF) maturation failure is a possible barrier to establishing permanent hemodialysis access. While overt stenosis is the most commonly cited cause, a substantial proportion of non-maturing fistulas lack angiographically apparent lesions, suggesting that subclinical hemodynamic and geometric factors play a critical role. This case describes a 65-year-old man with end-stage renal disease on hemodialysis, coronary artery disease status post right coronary artery (RCA) stent placement, ischemic cardiomyopathy (left ventricular ejection fraction (LVEF) 40-45%), and a history of sustained ventricular tachycardia requiring single-chamber transvenous implantable cardioverter defibrillator (ICD) placement, who underwent left upper extremity AVF creation ipsilateral to the device. Despite serial fistulograms demonstrating patent central veins without discrete stenosis, the fistula failed to mature over five months. The clinical course and sequential interventions--coil embolization of accessory venous branches, transvenous ICD extraction with subcutaneous ICD placement, and continued surveillance--were followed by clinical improvement and a patent AVF that was cleared for hemodialysis use. The temporal association between lead extraction and subsequent clinical improvement and clearance of the AVF for hemodialysis use is consistent with the hypothesis that the ipsilateral transvenous ICD lead may have contributed to delayed maturation through subclinical flow perturbation rather than overt mechanical stenosis. This case highlights the importance of considering ICD platform selection as a modifiable factor in dialysis access planning and illustrates the value of transitioning from transvenous to subcutaneous ICD to preserve vascular access in dialysis-dependent patients.