Examination of the mature hemodialysis arteriovenous fistula
- Gerald A Beathard, MD, PhD
Gerald A Beathard, MD, PhD
- Clinical Professor
- University of Texas Medical Branch
- 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
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Physical examination of the hemodialysis arteriovenous fistula (AVF) is easy and inexpensive and can often detect common problems associated with hemodialysis access [1-5].
This topic review provides a guide to the physical examination of the mature AVF. Examination of the newly created arteriovenous fistula is reviewed separately (see "Maturation and evaluation of the newly created hemodialysis arteriovenous fistula"). Complications of AVFs are discussed separately. (See "Failure of the mature hemodialysis arteriovenous fistula" and "Nonthrombotic complications of chronic hemodialysis arteriovenous vascular access".)
THE MATURE AV FISTULA: NORMAL EXAMINATION
The 2006 National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines recommend that physical examination (monitoring) be performed on all mature arteriovenous fistulas (AVFs) on a weekly basis . Such monitoring is also recommended by the 2008 Society for Vascular Surgery practice guidelines . We believe the hemodialysis arteriovenous fistula should be examined at every hemodialysis treatment. This requires that all clinical staff who are directly involved in the care of hemodialysis patients be familiar with the basic techniques used to examine the fistula. Routine systematic physical examination of the fistula by the dialysis staff with each treatment may allow early detection of problems that are commonly associated with mature fistula, thus avoiding missed treatments and emergent situations. (See 'Accuracy of physical examination' below and "Clinical monitoring and surveillance of the mature hemodialysis arteriovenous fistula" and 'Examination to detect specific problems' below.)
Inspection — Examination of the patient with a hemodialysis access includes inspection of the fistula itself as well as inspection of the entire extremity.
Fistula — The first step in a systematic evaluation of the mature AVF is to examine the integrity of the skin overlying the fistula, which should appear normal without erythema, focal masses, or focal swelling. Cannulation sites should be well healed with minimal to no scabbing and no evidence of inflammation. There should be no aneurysms (localized bulging zone) present. If an aneurysm is present, the skin overlying the bulging area should be examined for evidence of depigmentation, thinning, ulceration, or spontaneous bleeding. (See 'Aneurysms' below.)
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- THE MATURE AV FISTULA: NORMAL EXAMINATION
- - Fistula
- - Extremity
- - Pulse
- - Thrill
- - Direction of flow
- - Bruit
- EXAMINATION TO DETECT SPECIFIC PROBLEMS
- Stenotic vascular lesions
- - Physical findings
- - Testing for recirculation
- Thrombosed fistula
- Infected fistula
- Extremity ischemia
- - Dialysis ischemic steal syndrome
- - Ischemic monomelic neuropathy
- ACCURACY OF PHYSICAL EXAMINATION
- FURTHER DIAGNOSTIC TESTING
- SUMMARY AND RECOMMENDATIONS