Patient evaluation and vascular mapping prior to placement of hemodialysis arteriovenous access
- Gerald A Beathard, MD, PhD
Gerald A Beathard, MD, PhD
- Clinical Professor
- University of Texas Medical Branch
- Section Editors
- 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
- 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
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 . 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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- GOALS FOR AV ACCESS CREATION
- Ideal type of hemodialysis AV access
- Ideal AV access characteristics
- GENERAL EVALUATION
- Medical history
- General physical examination
- Side of access
- - Handedness
- - Other considerations
- ARTERIAL EVALUATION
- Physical examination
- - Arterial pulses
- - Differential blood pressures
- - Allen test
- Reactive hyperemia
- Arterial imaging
- Poor arteries
- VENOUS EVALUATION
- General characteristics
- Vein size
- Vein distensibility
- Inadequate veins
- Choice of technique for evaluating vein size
- - Physical examination
- - Ultrasound
- - Venography
- SUMMARY AND RECOMMENDATIONS