Duplex Ultrasound Evaluation for Dialysis access Selection and Maintenance: A Practical Guide

Abstract

Detailed case directed history and examination is the mainstay of dialysis access modality selection, ie site and type of access, as well as for maintenance of dialysis access for longevity. As a logical step following history and physical examination, duplex ultrasound evaluation (DUE) is the most cost effective and non-invasive screening tool for evaluation for access placement and for assessment of an established access. Pre-operative vascular mapping allows selection of the optimal dialysis access modality and site. In established accesses, duplex ultrasound testing will diagnose the majority of vascular access complications and direct proper surgical or interventional radiology management. This review outlines a practical decision-making algorithm using DUE for choosing and managing the dialysis access.

Color Doppler ultrasound and arteriovenous fistulas for hemodialysis

“…Generally, the physical examination conducted by an experienced dialysis nurse is sufficiently reliable for determining whether the fistula is mature and therefore ready for puncture [15]. The problem arises when the fistula does not appear clearly mature based on inspection alone, a situation that occurs with obese patients and with slow-maturing AVFs.…”

“…In fact, despite the obvious long-term advantages in terms of morbidity and mortality that make AVFs the vascular access of choice for hemodialysis patients [24], arteriovenous anastomoses with native vessels has been associated with a high incidence of early occlusion and failure to mature (FTM) during the postoperative period. In different case series, the incidence of FTM for radiocephalic AVFs ranged from 30 to 60 % [15,30].…”

“…Preoperative arterial DUS should include evaluation of subclavian, axillary, brachial, radial and ulnar arteries [15]. In clinical practice, however, most arterial evaluations begin with the distal subclavian artery or even the brachial artery [9,16]: only when anomalies are found at these levels, is the investigation extended to the proximal portion of the subclavian artery?…”

“…In obese subjects, for example, even veins that are well developed can be difficult to visualize or palpate because of their depth; in these cases, DUS can reveal whether the fistula is mature, and US mapping of the out-flow veins can facilitate the first cannulation and simplify subsequent punctures [15]. In this regard, it is important to recall the proposal of Rayner et al [31], which was incorporated in the K-DOQI Guidelines [24] as ''the Rule of 6''.…”

“…Even so, DUS should always be done before an AVF is first used. This examination provides baseline data on the vascular access, which can be useful in subsequent examinations performed to evaluate functional problems [15].…”