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.)
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Nov 08, 2016.References
- 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.
- 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.
- 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.
- Besarab A, Sherman R. The relationship of recirculation to access blood flow. Am J Kidney Dis 1997; 29:223.
- 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.
- Beathard GA, Spergel LM. Hand ischemia associated with dialysis vascular access: an individualized access flow-based approach to therapy. Semin Dial 2013; 26:287.
- Beathard GA. Physical examination of AV grafts. Semin Dial 1992; 5:74.
- 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.
- 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.
- Leon C, Orozco-Vargas LC, Krishnamurthy G, et al. Accuracy of physical examination in the detection of arteriovenous graft stenosis. Semin Dial 2008; 21:85.
- Beathard GA, Arnold P, Jackson J, et al. Aggressive treatment of early fistula failure. Kidney Int 2003; 64:1487.
- 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