Noninvasive Vascular Testing with the Surgeon Present in Planning and Maintenance of Arteriovenous Hemodialysis Access

Abstract

Background The goal of the study was to determine the incidence of upper extremity noninvasive vascular findings in guiding anatomic site and management strategies in the creation and maintenance of arteriovenous (AV) access for hemodialysis. All studies were performed with the surgeon present. Methods An ICAVL-accredited vascular laboratory database of upper extremity noninvasive vascular studies performed during a 12-month period was reviewed. The study group consisted of 152 end stage renal disease patients who received Doppler ultrasound and/or noninvasive physiologic testing for the purpose of assisting in planning or maintenance of hemodialysis access. The study group yielded a total of 252 exams as follows: (1) preoperative evaluation to determine site and suitability for use in AV access creation (n = 133); (2) existing AV access (AV fistula or graft) with clinical symptoms indicating malfunction and need for identifying the location and/or nature of the problem (n = 98); (3) finger arterial pressures and wave forms (with and without access compression) in patients with clinical symptoms of steal syndrome (n = 21). Results Of the 133 preoperative evaluations, 67 (51%) resulted in creation of an AV graft and 66 (49%) in an AV fistula. AV graft was chosen over fistula because of duplex findings of inadequate (<2 mm in diameter) or deep (>7 mm below skin level) veins. In all cases, the site and arm were determined by duplex findings and were marked preoperatively by the surgeon. In 72 (73.5%) of the 98 malfunctioning AV accesses, the etiology and site were identified by duplex ultrasound. These included thrombosing/failing access (n = 18, 25%), outflow venous stenosis (n = 16, 22.2%), inflow arterial stenosis (n = 15, 20.8%), anastomotic stenosis (n = 9, 12.5%), and miscellaneous causes (n = 14, 19.5%). Again, sites were marked by the access surgeon to guide intraoperative management. Steal was confirmed to be present in 11 (52%) of 21 patients and the surgeon determined the degree of arterial banding based on intraoperative changes in digital pressures. Conclusions Preoperative duplex scanning of upper extremity vasculature with the access surgeon present allows for accurate and precise planning in the creation of AV access. This has the potential to improve compliance with K/DOQI guidelines. Success in rescuing failing angioaccess is also enhanced by non-invasive testing in the presence of the operating surgeon.