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, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- 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
- 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
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 arteriovenous hemodialysis 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.)
- Beathard GA. Physical examination of the dialysis vascular access. Semin Dial 1998; 11:231.
- Trerotola SO, Scheel PJ Jr, Powe NR, et al. Screening for dialysis access graft malfunction: comparison of physical examination with US. J Vasc Interv Radiol 1996; 7:15.
- Safa AA, Valji K, Roberts AC, et al. Detection and treatment of dysfunctional hemodialysis access grafts: effect of a surveillance program on graft patency and the incidence of thrombosis. Radiology 1996; 199:653.
- Migliacci R, Selli ML, Falcinelli F, et al. Assessment of occlusion of the vascular access in patients on chronic hemodialysis: comparison of physical examination with continuous-wave Doppler ultrasound. STOP Investigators. Shunt Thrombotic Occlusion Prevention with Picotamide. Nephron 1999; 82:7.
- 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.
- 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.
- Mishler R, Schon D, Hubert B, Nissenson AR. Development and usefulness of a physical examination tool to diagnose vascular access dysfunction. J Am Soc Nephrol 2000; 11:190A.
- Haage P, Vorwerk D, Wildberger JE, et al. Percutaneous treatment of thrombosed primary arteriovenous hemodialysis access fistulae. Kidney Int 2000; 57:1169.
- Wixon CL, Hughes JD, Mills JL. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access. J Am Coll Surg 2000; 191:301.
- Lazarides MK, Staramos DN, Panagopoulos GN, et al. Indications for surgical treatment of angioaccess-induced arterial "steal". J Am Coll Surg 1998; 187:422.
- Zamani P, Kaufman J, Kinlay S. Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis. Vasc Med 2009; 14:371.
- Miles AM. Vascular steal syndrome and ischaemic monomelic neuropathy: two variants of upper limb ischaemia after haemodialysis vascular access surgery. Nephrol Dial Transplant 1999; 14:297.
- Leon C, Asif A. Physical examination of arteriovenous fistulae by a renal fellow: does it compare favorably to an experienced interventionalist? Semin Dial 2008; 21:557.
- Tessitore N, Bedogna V, Melilli E, et al. In search of an optimal bedside screening program for arteriovenous fistula stenosis. Clin J Am Soc Nephrol 2011; 6:819.
- Campos RP, Chula DC, Perreto S, et al. Accuracy of physical examination and intra-access pressure in the detection of stenosis in hemodialysis arteriovenous fistula. Semin Dial 2008; 21:269.
- Depner TA. Techniques for prospective detection of venous stenosis. Adv Ren Replace Ther 1994; 1:119.
- Choi J, Kim Y, Yoon S. Accuracy of physical examination in the detection of arteriovenous fistula dysfunction. Korean J Nephrol 2006; 25:797.
- Beathard GA, Arnold P, Jackson J, et al. Aggressive treatment of early fistula failure. Kidney Int 2003; 64:1487.
- 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