Clinical monitoring and surveillance of the mature hemodialysis arteriovenous fistula
- Michael Allon, MD
Michael Allon, MD
- Professor of Medicine
- University of Alabama at Birmingham
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
Arteriovenous fistulas (AVFs) are capable of providing rapid extracorporeal blood flow that is necessary for hemodialysis; however, vascular stenosis is common and can lead to inadequate hemodialysis or fistula thrombosis if not identified and treated in a timely fashion.
Issues surrounding monitoring and surveillance of hemodialysis AVFs are reviewed here. Similar issues for hemodialysis AV grafts are discussed separately. (See "Monitoring and surveillance of hemodialysis arteriovenous grafts to prevent thrombosis".)
RATIONALE FOR MONITORING AND SURVEILLANCE OF AV FISTULAS
Nearly all thrombosed mature fistulas have an underlying stenotic lesion. This was shown in a series of 93 consecutive clotted fistulas in which 100 percent had an underlying stenosis . (See "Failure of the mature hemodialysis arteriovenous fistula".)
Although angiography is the most sensitive and specific imaging modality to identify and characterize stenotic vascular lesions, it is expensive and invasive [2-6]. For screening, noninvasive assessment is preferred to first identify fistulas with a high likelihood of stenosis. AVFs with sufficiently abnormal screening tests would then undergo diagnostic angiography and, if indicated, treatment. Clinical monitoring and surveillance are currently used to screen for vascular stenotic lesions.
●Clinical monitoring (see 'Clinical monitoring' below)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Turmel-Rodrigues L, Pengloan J, Rodrigue H, et al. Treatment of failed native arteriovenous fistulae for hemodialysis by interventional radiology. Kidney Int 2000; 57:1124.
- Schwab SJ, Raymond JR, Saeed M, et al. Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses. Kidney Int 1989; 36:707.
- Beathard GA. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis. Kidney Int 1992; 42:1390.
- Windus DW, Audrain J, Vanderson R, et al. Optimization of high-efficiency hemodialysis by detection and correction of fistula dysfunction. Kidney Int 1990; 38:337.
- Schwab SJ, Saeed M, Sussman SK, et al. Transluminal angioplasty of venous stenoses in polytetrafluoroethylene vascular access grafts. Kidney Int 1987; 32:395.
- Collins DM, Lambert MB, Middleton JP, et al. Fistula dysfunction: effect on rapid hemodialysis. Kidney Int 1992; 41:1292.
- Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int 2002; 62:1109.
- Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 Suppl 1:S248.
- Sidawy AN, Spergel LM, Besarab A, et al. The Society for Vascular Surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg 2008; 48:2S.
- Asif A, Leon C, Orozco-Vargas LC, et al. Accuracy of physical examination in the detection of arteriovenous fistula stenosis. Clin J Am Soc Nephrol 2007; 2:1191.
- Polkinghorne KR, Lau KK, Saunder A, et al. Does monthly native arteriovenous fistula blood-flow surveillance detect significant stenosis--a randomized controlled trial. Nephrol Dial Transplant 2006; 21:2498.
- Schwarz C, Mitterbauer C, Boczula M, et al. Flow monitoring: performance characteristics of ultrasound dilution versus color Doppler ultrasound compared with fistulography. Am J Kidney Dis 2003; 42:539.
- Tonelli M, Hirsch D, Clark TW, et al. Access flow monitoring of patients with native vessel arteriovenous fistulae and previous angioplasty. J Am Soc Nephrol 2002; 13:2969.
- Tessitore N, Bedogna V, Gammaro L, et al. Diagnostic accuracy of ultrasound dilution access blood flow measurement in detecting stenosis and predicting thrombosis in native forearm arteriovenous fistulae for hemodialysis. Am J Kidney Dis 2003; 42:331.
- Tonelli M, Jindal K, Hirsch D, et al. Screening for subclinical stenosis in native vessel arteriovenous fistulae. J Am Soc Nephrol 2001; 12:1729.
- Tonelli M, James M, Wiebe N, et al. Ultrasound monitoring to detect access stenosis in hemodialysis patients: a systematic review. Am J Kidney Dis 2008; 51:630.
- Besarab A, Sullivan KL, Ross RP, Moritz MJ. Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis. Kidney Int 1995; 47:1364.
- Maya ID, Oser R, Saddekni S, et al. Vascular access stenosis: comparison of arteriovenous grafts and fistulas. Am J Kidney Dis 2004; 44:859.
- McCarley P, Wingard RL, Shyr Y, et al. Vascular access blood flow monitoring reduces access morbidity and costs. Kidney Int 2001; 60:1164.
- Shahin H, Reddy G, Sharafuddin M, et al. Monthly access flow monitoring with increased prophylactic angioplasty did not improve fistula patency. Kidney Int 2005; 68:2352.
- Tessitore N, Mansueto G, Bedogna V, et al. A prospective controlled trial on effect of percutaneous transluminal angioplasty on functioning arteriovenous fistulae survival. J Am Soc Nephrol 2003; 14:1623.
- Tessitore N, Mansueto G, Lipari G, et al. Endovascular versus surgical preemptive repair of forearm arteriovenous fistula juxta-anastomotic stenosis: analysis of data collected prospectively from 1999 to 2004. Clin J Am Soc Nephrol 2006; 1:448.
- Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
- NKF-K/DOQI Clinical Practice Guidelines For Vascular Access. Clinical Practice Guideline 4: Detection of access dysfunction: monitoring, surveillance, and diagnostic testing. Am J Kidney Dis 2006; 48(Suppl 1):S248.
- Gray RJ. Percutaneous intervention for permanent hemodialysis access: a review. J Vasc Interv Radiol 1997; 8:313.
- Vesely TM. Percutaneous transluminal angioplasty for the treatment of failing hemodialysis grafts and fistulae. Semin Dial 1998; 11:351.
- RATIONALE FOR MONITORING AND SURVEILLANCE OF AV FISTULAS
- CLINICAL MONITORING
- Routine examination
- Problems with dialysis
- Decreased Kt/V
- Intra-access flow rate
- Duplex ultrasound
- Static dialysis venous pressure
- INDICATIONS FOR ANGIOGRAPHY REFERRAL
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS