Diagnostic accuracy of ultrasound dilution access blood flow measurement in detecting stenosis and predicting thrombosis in native forearm arteriovenous fistulae for hemodialysis

Tessitore, Nicola; Bedogna, Valeria; Gammaro, Linda; Lipari, Giovanni; Poli, Albino; Baggio, Elda; Firpo, Maria; Morana, Giovanni; Mansueto, Giancarlo; Maschio, Giuseppe

doi:10.1016/s0272-6386(03)00659-0

Cited by 93 publications

(73 citation statements)

References 24 publications

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“…The study by Tessitore et al [56] showed that fistula stenosis can be detected and located during dialysis with a moderate-to-excellent accuracy using physical examination and Qa measurement as screening procedures, or ultrasound dilution Qa measurement which is a reproducible and highly accurate tool for detecting stenosis and predicting thrombosis in forearm AVFs. Neither Qa/ MAP nor dQa improve the diagnostic performance of Qa alone, although its combination with dQa increases the test's sensitivity for stenosis [57] , and all these diagnostic tests with respect to the value of physical examination itself [58] . Hemoglobin dilution technique can be used to measure VA flow but requires validation against clinical outcomes before being recommended as an alternative to UDT [59] .…”

Section: Permanent Vamentioning

confidence: 96%

Vascular access today

Pantelias

Grapsa²

2012

WJN

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The number of patients with chronic kidney disease requiring renal replacement therapy has increased worldwide. The most common replacement therapy is hemodialysis (HD). Vascular access (VA) has a key role for successful treatment. Despite the advances that have taken place in the field of the HD procedure, few things have changed with regards to VA in recent years. Arteriovenous fistula (AVF), polytetrafluoroethylene graft and the cuffed double lumen silicone catheter are the most common used for VA. In the long term, a number of complications may present and more than one VA is needed during the HD life. The most common complications for all of VA types are thrombosis, bleeding and infection, the most common cause of morbidity in these patients. It has been estimated that VA dysfunction is responsible for 20% of all hospitalizations. The annual cost of placing and looking after dialysis VA in the United States exceeds 1 billion dollars per year. A good functional access is also vital in order to deliver adequate HD therapy. It seems that the native AVF that Brescia and Cimino described in 1966 still remains the first choice for VA. The native forearm AVFs have the longest survival and require the fewest interventions. For this reason, the forearm AVF is the first choice, followed by the upper-arm AVF, the arteriovenous graft and the cuffed central venous catheter is the final choice. In conclusion, VA remains the most important issue for patients on HD and despite the technical improvements, a number of problems and complications have to be resolved.

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Section: Permanent Vamentioning

confidence: 96%

Vascular access today

Pantelias

Grapsa²

2012

WJN

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“…It has been shown, however, that the site of stenosis varies according to the type of AVF, the most common location being the juxta-anastomotic region in the case of forearm radiocephalic AVFs, and the outflow region for upper-arm brachiocephalic and brachiobasilic AVFs (2)(3)(4)(5). It has also been reported that the access blood flow rate (Qa), a measurement widely accepted as a means for detecting access dysfunction, also varies according to the site of the AVF, being lower in the more distal accesses than in the more proximal accesses (6,7). Some researchers have found that the Qa threshold indicative of stenosis is lower in the wrist than in mid-forearm AVFs (6), and others have suggested that the Qa threshold warranting imaging and intervention should depend on access site, a Qa limit of 400 ml/min being acceptable in the forearm as opposed to 600 ml/min in the upper arm AVFs (8).…”

Section: Introductionmentioning

confidence: 99%

“…It has also been reported that the access blood flow rate (Qa), a measurement widely accepted as a means for detecting access dysfunction, also varies according to the site of the AVF, being lower in the more distal accesses than in the more proximal accesses (6,7). Some researchers have found that the Qa threshold indicative of stenosis is lower in the wrist than in mid-forearm AVFs (6), and others have suggested that the Qa threshold warranting imaging and intervention should depend on access site, a Qa limit of 400 ml/min being acceptable in the forearm as opposed to 600 ml/min in the upper arm AVFs (8). The tools and criteria to use in screening for stenoses may therefore conceivably vary according to the site of the anastomosis, but no studies have systematically addressed this issue to date.…”

Section: Introductionmentioning

confidence: 99%

Bedside Screening for Fistula Stenosis Should Be Tailored to the Site of the Arteriovenous Anastomosis

Tessitore¹,

Bedogna²,

Lipari³

et al. 2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Given different sites of stenosis and access blood flow rates (Qa), the criteria for diagnosing fistula stenosis might vary according to anastomotic site. To test this, we analyzed the database of a prospective blinded study seeking an optimal bedside screening program for fistula stenosis.Design, setting, participants, & measurements Several methods used during dialysis (physical examination [PE], dynamic and derived static venous pressure [VAPR], dialysis blood pump flow/arterial pressure ratio, and Qa measurement) to diagnose angiographically-proven Ͼ50% stenosis were assessed in an unselected population of hemodialysis patients with mature fistulae (43 at the wrist [distal fistulae], 76 at midforearm or the elbow [proximal fistulae]).Results Prevalence of inflow stenosis was uninfluenced by anastomotic site, whereas outflow stenoses were more prevalent in proximal fistulae. The best test for inflow stenosis was Qa Ͻ650 ml/min in distal fistulae and a combination of a positive PE and Qa Ͻ900 ml/m in proximal fistulae. In proximal fistulae, PE and VAPR Ͼ0.5 were both equally highly diagnostic of outflow stenosis. Tailoring choice of test to site of the anastomosis may also contain the screening-associated workload, by reducing the need to perform PE and measure VAPR, compared with a screening approach regardless of the access location. ConclusionsOur study shows that an effective bedside screening program with Ն85% accuracy for fistula stenosis can be tailored to the site of the anastomosis, Qa being the tool of choice for the wrist, and PE alone or combined with Qa and VAPR measurements for more proximally-located accesses.

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“…Another monitoring method growing in use is Doppler flow measurement. If the flow decreases to less than 650 mL/minute, or if there has been significant interval decrease in flow, there is a high likelihood of stenosis (94). Stenoses can be detected by Doppler ultrasound, but the gold standard for detection and treatment of access stenosis is fistulogram, or the injection of contrast into the access to demonstrate visually the stenosis.…”

Section: Detection and Treatment Of Stenosis And Thrombosis Of Avf Anmentioning

confidence: 99%