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Patient evaluation and vascular mapping prior to placement of hemodialysis arteriovenous access

Author
Gerald A Beathard, MD, PhD
Section Editors
David L Cull, MD
Jeffrey S Berns, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

An arteriovenous (AV) hemodialysis access is a deliberate connection between an artery and vein achieved by anastomosing native vessels or by the interposition of graft material. The goal of AV access creation is to provide an accessible vascular structure with sufficient blood flow that can be cannulated repeatedly to permit adequate dialysis. The medical and physical evaluation of the dialysis patient with chronic kidney disease (CKD) who is preparing for hemodialysis enhances the opportunity to place the most appropriate AV access for that patient. Ideally, the evaluation will identify anatomy suitable for the creation of an AV fistula. In most patients, only after determining that conditions are not suitable for an AV fistula should an AV graft be considered.

With the requirements necessary for a properly functioning AV access in mind, evaluation of the patient for hemodialysis arteriovenous access should include the patient's medical history, physical examination, and vascular mapping. In selected patients, specific arterial and venous evaluations may also be required. (See "Creating an arteriovenous fistula for hemodialysis".)

GOALS FOR AV ACCESS CREATION

When a hemodialysis arteriovenous (AV) access is created between the arterial and venous circulation, the goal is to create an accessible vascular structure with sufficient blood flow that can be cannulated repeatedly to permit adequate dialysis. The ideal type and characteristics for hemodialysis AV access are reviewed in the next sections.

Ideal type of hemodialysis AV access — The patient's age, presence of significant comorbid conditions, malnutrition, and functional status factor into the decision of whether to start dialysis therapy in the first place, but these same factors should also guide the type of vascular access when hemodialysis is selected [1]. Whether an AV fistula, AV graft, or tunneled dialysis catheter is most appropriate must be an individualized decision. (See "Overview of chronic hemodialysis vascular access", section on 'Recommended strategy for chronic hemodialysis vascular access'.)

Many chronic kidney disease (CKD) patients approaching hemodialysis will have anatomy that is suitable for an AV fistula placement, which should be the first-line choice in most patients. However, because of the time required for AV fistula maturation and the high incidence of nonmaturation, an AV graft would be more appropriate for those in whom vascular anatomy is not suitable for the creation of an AV fistula as determined by vascular mapping. In these patients, placement of an AV graft serves three functions. It provides a functioning AV access that can be used early, it allows maturation of the veins draining the access that may eventually support the creation of a secondary AV fistula, and it avoids placement of a dialysis catheter. (See "Overview of chronic hemodialysis vascular access", section on 'Comparison of AV fistulas and AV grafts'.)

                         

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Literature review current through: Nov 2016. | This topic last updated: Wed Nov 23 00:00:00 GMT+00:00 2016.
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References
Top
  1. Clinical Practice Guideline for Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, 2nd ed, Renal Physicians Association, Rockville, MD 2010.
  2. Lauvao LS, Ihnat DM, Goshima KR, et al. Vein diameter is the major predictor of fistula maturation. J Vasc Surg 2009; 49:1499.
  3. Silva MB Jr, Hobson RW 2nd, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg 1998; 27:302.
  4. Jennings WC, Kindred MG, Broughan TA. Creating radiocephalic arteriovenous fistulas: technical and functional success. J Am Coll Surg 2009; 208:419.
  5. Robbin ML, Chamberlain NE, Lockhart ME, et al. Hemodialysis arteriovenous fistula maturity: US evaluation. Radiology 2002; 225:59.
  6. Asif A, Roy-Chaudhury P, Beathard GA. Early arteriovenous fistula failure: a logical proposal for when and how to intervene. Clin J Am Soc Nephrol 2006; 1:332.
  7. NKF-K/DOQI Clinical Practice Guidelines For Vascular Access: Update 2006. Guideline 1: Patient preparation for permanent hemodialysis access, 1.4 History and physical examination. http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/va_guide1.htm (Accessed on October 07, 2016).
  8. Lok CE, Allon M, Moist L, et al. Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I). J Am Soc Nephrol 2006; 17:3204.
  9. Beathard GA. Complications of vascular access. In: Complications of dialysis, Lameire N and Mehta R (Ed), Marcel Dekker, Inc, New York 2000. p.1.
  10. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg 2002; 35:603.
  11. 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.
  12. Ruland O, Borkenhagen N, Prien T. [The Doppler palm test]. Ultraschall Med 1988; 9:63.
  13. Paul BZ, Feeney CM. Combining the Modified Allen's Test and Pulse Oximetry for Evaluating Ulnar Collateral Circulation to the Hand for Radial Artery Catheterization of the ED Patient. Cal J Emerg Med 2003; 4:89.
  14. Agrifoglio M, Dainese L, Pasotti S, et al. Preoperative assessment of the radial artery for coronary artery bypass grafting: is the clinical Allen test adequate? Ann Thorac Surg 2005; 79:570.
  15. Hirai M, Kawai S. False positive and negative results in Allen test. J Cardiovasc Surg (Torino) 1980; 21:353.
  16. Kamienski RW, Barnes RW. Critique of the Allen test for continuity of the palmar arch assessed by doppler ultrasound. Surg Gynecol Obstet 1976; 142:861.
  17. Malovrh M. Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis 2002; 39:1218.
  18. Malovrh M. Non-invasive evaluation of vessels by duplex sonography prior to construction of arteriovenous fistulas for haemodialysis. Nephrol Dial Transplant 1998; 13:125.
  19. Wall LP, Gasparis A, Callahan S, et al. Impaired hyperemic response is predictive of early access failure. Ann Vasc Surg 2004; 18:167.
  20. Joannides R, Haefeli WE, Linder L, et al. Nitric oxide is responsible for flow-dependent dilatation of human peripheral conduit arteries in vivo. Circulation 1995; 91:1314.
  21. Georgiadis GS, Charalampidis DG, Argyriou C, et al. The Necessity for Routine Pre-operative Ultrasound Mapping Before Arteriovenous Fistula Creation: A Meta-analysis. Eur J Vasc Endovasc Surg 2015; 49:600.
  22. Wong V, Ward R, Taylor J, et al. Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg 1996; 12:207.
  23. Parmar J, Aslam M, Standfield N. Pre-operative radial arterial diameter predicts early failure of arteriovenous fistula (AVF) for haemodialysis. Eur J Vasc Endovasc Surg 2007; 33:113.
  24. Korten E, Toonder IM, Schrama YC, et al. Dialysis fistulae patency and preoperative diameter ultrasound measurements. Eur J Vasc Endovasc Surg 2007; 33:467.
  25. Lazarides MK, Georgiadis GS, Tzilalis VD. Diabetes should not preclude efforts for creation of a primary radiocephalic fistula. Nephrol Dial Transplant 2002; 17:1852.
  26. Nicolosi AC, Pohl LL, Parsons P, et al. Increased incidence of radial artery calcification in patients with diabetes mellitus. J Surg Res 2002; 102:1.
  27. Napoli M, Montinaro A, Russo F, et al. Early experiences of intraoperative ultrasound guided angioplasty of the arterial stenosis during upper limb arteriovenous fistula creation. J Vasc Access 2007; 8:97.
  28. Lee T, Chauhan V, Krishnamoorthy M, et al. Severe venous neointimal hyperplasia prior to dialysis access surgery. Nephrol Dial Transplant 2011; 26:2264.
  29. Lee T, Safdar N, Mistry MJ, et al. Preexisting venous calcification prior to dialysis vascular access surgery. Semin Dial 2012; 25:592.
  30. Kim JT, Chang WH, Oh TY, Jeong YK. Venous distensibility as a key factor in the success of arteriovenous fistulas at the wrist. Ann Vasc Surg 2011; 25:1094.
  31. van der Linden J, Lameris TW, van den Meiracker AH, et al. Forearm venous distensibility predicts successful arteriovenous fistula. Am J Kidney Dis 2006; 47:1013.
  32. Jemcov TK. Morphologic and functional vessels characteristics assessed by ultrasonography for prediction of radiocephalic fistula maturation. J Vasc Access 2013; 14:356.
  33. Mendes RR, Farber MA, Marston WA, et al. Prediction of wrist arteriovenous fistula maturation with preoperative vein mapping with ultrasonography. J Vasc Surg 2002; 36:460.
  34. Tordoir JH, Rooyens P, Dammers R, et al. Prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis. Nephrol Dial Transplant 2003; 18:378.
  35. Nursal TZ, Oguzkurt L, Tercan F, et al. Is routine preoperative ultrasonographic mapping for arteriovenous fistula creation necessary in patients with favorable physical examination findings? Results of a randomized controlled trial. World J Surg 2006; 30:1100.
  36. Ferring M, Claridge M, Smith SA, Wilmink T. Routine preoperative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis: a randomized trial. Clin J Am Soc Nephrol 2010; 5:2236.
  37. Gaudino M, Serricchio M, Luciani N, et al. Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula. Circulation 2003; 107:2653.
  38. Tan CS, Fintelmann F, Joe J, et al. Coronary-subclavian steal syndrome in a hemodialysis patient, a case report and review of literature. Semin Dial 2013; 26:E42.
  39. Robbin ML, Gallichio MH, Deierhoi MH, et al. US vascular mapping before hemodialysis access placement. Radiology 2000; 217:83.
  40. Malovrh M. The role of sonography in the planning of arteriovenous fistulas for hemodialysis. Semin Dial 2003; 16:299.
  41. Mihmanli I, Besirli K, Kurugoglu S, et al. Cephalic vein and hemodialysis fistula: surgeon's observation versus color Doppler ultrasonographic findings. J Ultrasound Med 2001; 20:217.
  42. Jennings WC, Parker DE. Creating arteriovenous fistulas using surgeon-performed ultrasound. J Vasc Access 2016; 17:333.
  43. Gooding GA, Hightower DR, Moore EH, et al. Obstruction of the superior vena cava or subclavian veins: sonographic diagnosis. Radiology 1986; 159:663.
  44. Grassi CJ, Polak JF. Axillary and subclavian venous thrombosis: follow-up evaluation with color Doppler flow US and venography. Radiology 1990; 175:651.
  45. Robbin ML, Oser RF, Allon M, et al. Hemodialysis access graft stenosis: US detection. Radiology 1998; 208:655.
  46. Elsharawy MA, Moghazy KM. Impact of pre-operative venography on the planning and outcome of vascular access for hemodialysis patients. J Vasc Access 2006; 7:123.
  47. Hyland K, Cohen RM, Kwak A, et al. Preoperative mapping venography in patients who require hemodialysis access: imaging findings and contribution to management. J Vasc Interv Radiol 2008; 19:1027.
  48. Karakayali FY, Sevmis S, Basaran C, et al. Relationship of preoperative venous and arterial imaging findings to outcomes of brachio-basilic transposition fistulae for hemodialysis: a prospective clinical study. Eur J Vasc Endovasc Surg 2008; 35:208.
  49. Asif A, Cherla G, Merrill D, et al. Venous mapping using venography and the risk of radiocontrast-induced nephropathy. Semin Dial 2005; 18:239.
  50. Kian K, Wyatt C, Schon D, et al. Safety of low-dose radiocontrast for interventional AV fistula salvage in stage 4 chronic kidney disease patients. Kidney Int 2006; 69:1444.