An Algorithm for the Physical Examination of Early Fistula Failure

Abstract

Evaluation of a newly created fistula 4-6 weeks after surgery should be considered mandatory. If the fistula is going to become adequate for dialysis, it will be apparent at this time. This evaluation can be accomplished by physical examination. However, it must be performed by someone who is knowledgeable. Using a systematic approach facilitates the evaluation and ensures that a problem is not overlooked. Once it is determined that the fistula is dysfunctional, the case should be immediately referred for management to an interventionalist who is experienced in dealing with early fistula failure. The majority of these cases can be salvaged.

Accuracy of Physical Examination in the Detection of Arteriovenous Fistula Stenosis

“…The diagnostic elements of the physical examination used in the evaluation of an outflow lesion included the presence of a water-hammer pulse (hyperpulsation), systolic thrill (bruit), and abnormal arm elevation test (2)(3)(4). Physical examination in the diagnosis of outflow stenosis demonstrated excellent sensitivity and specificity (92 and 86%, respectively) with an outstanding value (0.78; Tables 1 and 2).…”

“…A complete physical examination was performed by an interventional nephrologist in all of the patients before any angiography was undertaken. The elements of the physical examination used in this study were based on recent information by Beathard and colleagues (2)(3)(4)(5)(6). Briefly, inspection (arm, shoulder, breast, neck, and face edema and presence of collaterals), palpation, and auscultation were performed in a systematic manner.…”

“…Pulse augmentation was performed by complete occlusion of the access several centimeters beyond the arterial anastomosis and evaluation of the strength of the pulse. The test was considered normal when the portion of fistula upstream from the occluding finger demonstrated augmentation of pulse (4,8). Arm elevation test was performed by elevation of the extremity with the fistula and examination of the normal collapse of the access (4).…”

Fistula First Initiative

“…The time from surgical referral to actual creation varies among surgeons, institutions, and countries, ranging from 2 wk (United States), to 1 mo (Europe), to 2 mo (Canada) (37). Another 4 to 8 wk are required to determine whether a fistula is going to mature (96,101), and then time is required to book the appropriate intervention, have it done (this may take another 2 wk), and then monitor again for 2 to 6 wk to determine whether the fistula will mature. Approximately 4 mo have now passed, and if another fistula is required, then there is not enough time for a new fistula to be created and adequately matured before the patient's first dialysis (31).…”

We Need to Train the Trainers

“…Physical examination has been shown to be very accurate in assessing an AVF and is not difficult to learn (23)(24)(25). If the AVF does not appear to be developing adequately for eventual use as a dialysis vascular access, a detailed physical examination of the vascular access will, in most instances, reveal the cause of the arrested maturation (26,27). Unfortunately, in many nephrology fellowship programs, adequate training in this area is not provided.…”