Physical examination of the arteriovenous graft
- 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
Physical examination of the hemodialysis arteriovenous (AV) graft is easy, inexpensive, and detects the common problems associated with a dialysis vascular access [1-5]. For the nephrologist and nonphysician clinical staff working with hemodialysis patients, physical examination of the AV graft should be a basic skill. The basic principles are easily learned and are similar to those for examining an arteriovenous fistula; however, physical examination of the AV graft is not as sensitive as performed on a fistula for the detection of stenotic lesions and flow related dysfunction . Nevertheless, it is a good technique for detecting significant clinical problems and should be performed.
This topic review provides a guide to the physical examination of the AV graft. Physical examination of the arteriovenous fistula is discussed separately. (See "Maturation and evaluation of the newly created hemodialysis arteriovenous fistula" and "Examination of the mature hemodialysis arteriovenous fistula".)
AV GRAFT: 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 arteriovenous (AV) accesses at least monthly. Such monitoring is also recommended by the 2008 Society for Vascular Surgery Guidelines . We believe that the AV graft and overlying skin should be examined at every hemodialysis treatment, and follow-up with a detailed physical examination of the access if any clinical abnormalities are present such as arm swelling, prolonged bleeding after the needles are pulled, poor blood flow, or difficulty with cannulation. This requires that all clinical staff that are directly involved in the care of hemodialysis patients be familiar with the basic techniques utilized in the examination of an AV graft. Routine physical examination of the AV graft by the dialysis staff allows for early detection of the major problems that are commonly associated with arteriovenous accesses, thus avoiding missed treatments and emergent situations. (See "Monitoring and surveillance of hemodialysis arteriovenous grafts to prevent thrombosis" and 'Examination to detect specific problems' below.)
Inspection — Routine examination of the patient with a hemodialysis access includes inspection of the graft itself as well as inspection of the entire extremity.
AV graft — The first step in a systematic evaluation is to examine the AV graft and the overlying skin. The skin should be intact and normal in appearance without areas of discoloration (erythema, bruising, depigmentation). Cannulation sites should be well healed with minimal to no scabbing and no evidence of inflammation or infection (erythema, pustules, swelling, fluctuance). The graft should be examined for areas of bulging (ie, localized dilation of the graft) or constriction. These generally represent the development of a pseudoaneurysm. This could be acute if not present on the previous examination or chronic if not a new discovery. If bulging is present, the skin overlying the area should be examined for evidence of thinning, ulceration, or spontaneous bleeding. (See 'Pseudoaneurysms' below.)
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- AV GRAFT: NORMAL EXAMINATION
- - AV graft
- - Extremity
- - Pulse
- - Thrill
- - Direction of flow
- EXAMINATION TO DETECT SPECIFIC PROBLEMS
- Stenotic vascular lesions
- - Intragraft or venous outflow stenosis
- - Arterial stenosis
- - Central vein stenosis
- Thrombosed graft
- Infected graft
- Extremity ischemia
- ACCURACY OF PHYSICAL EXAMINATION
- FURTHER DIAGNOSTIC TESTING
- SUMMARY AND RECOMMENDATIONS