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How to examine AVF in 10 minutes - Dr. Gawad

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How to examine AVF in 10 minutes - Dr. Gawad

  1. 1. How to examine AVF in 10 minutes Mohammed Abdel Gawad Nephrology Specialist Kidney & Urology Center (KUC) Alexandria – EGY drgawad@gmail.com 18th KUC Club – 19, Aug, 2016
  2. 2. To get the presentation with full animations and videos please contact me on drgawad@gmail.com For more presentations visit www.NephroTubeCNE.com
  3. 3. Functioning AVF = Patient’s life =
  4. 4. AVF Examination: Dose it matter? Early Detection of Complications Semin Dial. 2008;21:269–273.
  5. 5. Good AVF Examination = Early detection of complications = Saving AVF = Saving patient’s life AVF Examination: Dose it matter? AVF Examination Equation
  6. 6. Good AVF Examination = Early detection of complications = Saving AVF = Saving patient’s life AVF Examination: Dose it matter? AVF Examination Equation
  7. 7. KDOQI 2006 Monitoring the access
  8. 8. Important Concept AVF is a continuous circuit Examination should also include the remaining part of arm, shoulder, breast, neck, and face Examination should not be limited to the site of the AV access Don’t think about AVF as it is only anastomosis in the arm. AVF is a continuous circuit which starts at the heart and ends at the heart
  9. 9. How to Examine AVF?
  10. 10. How to Examine AVF? 1. Vascular access scar site 2. Signs of infection/inflammation 3. Hematoma 4. Signs of ischemia (Steal syndrome) 5. Aneurysm 6. Arm elevation test 7. Collaterals (Central vein stenosis)
  11. 11. How to Examine AVF? 1. Vascular access scar site 2. Signs of infection/inflammation 3. Hematoma 4. Signs of ischemia (Steal syndrome) 5. Aneurysm 6. Arm elevation test 7. Collaterals (Central vein stenosis)
  12. 12. Inspection 1- Vascular Access Scar Anatomy of Upper Extremity Vessels
  13. 13. Inspection 1- Vascular Access Scar Radiocephalic AVF
  14. 14. Inspection 1- Vascular Access Scar Snuff-box AVF
  15. 15. Inspection 1- Vascular Access Scar Brachiocephalic AVF
  16. 16. Inspection 1- Vascular Access Scar Transposed Basilic Vein AVF
  17. 17. Inspection 1- Vascular Access Scar Transposed Forearm Cephalic Vein AVF
  18. 18. Inspection 1- Vascular Access Scar Transposed Forearm Basilic Vein AVF
  19. 19. How to Examine AVF? 1. Vascular access scar site 2. Signs of infection/inflammation 3. Hematoma 4. Signs of ischemia (Steal syndrome) 5. Aneurysm 6. Arm elevation test 7. Collaterals (Central vein stenosis)
  20. 20. How to Examine AVF? 1. Vascular access scar site 2. Signs of infection/inflammation 3. Hematoma 4. Signs of ischemia (Steal syndrome) 5. Aneurysm 6. Arm elevation test 7. Collaterals (Central vein stenosis)
  21. 21. Inspection 2- Signs of Infection/Inflammation ± Pain/Fever
  22. 22. Inspection 2- Signs of Infection/Inflammation ± Pain/Fever
  23. 23. Inspection 2- Signs of Infection/Inflammation Skin Rash
  24. 24. Inspection 3- Hematoma
  25. 25. Inspection 4- Signs of Ischemia (Steal Syndrome)
  26. 26. Fingers are blue and cold Hand pain rest/exercise Paresthesia Inspection 4- Signs of Ischemia (Steal Syndrome)
  27. 27. Ulcers Inspection 4- Signs of Ischemia (Steal Syndrome)
  28. 28. (A) Early chronic ischemia of hand without tissue loss (hand was cold). (B) Tissue loss at the fingertip is evident (dry gangrene). Inspection 4- Signs of Ischemia (Steal Syndrome)
  29. 29. How to Examine AVF? 1. Vascular access scar site 2. Signs of infection/inflammation 3. Hematoma 4. Signs of ischemia (Steal syndrome) 5. Aneurysm 6. Arm elevation test 7. Collaterals (Central vein stenosis)
  30. 30. How to Examine AVF? 1. Vascular access scar site 2. Signs of infection/inflammation 3. Hematoma 4. Signs of ischemia (Steal syndrome) 5. Aneurysm 6. Arm elevation test 7. Collaterals (Central vein stenosis)
  31. 31. Inspection 5- Aneurysms Stable Aneurysm
  32. 32. Inspection 5- Aneurysms • Thin, shiny skin • Prolonged leaking • Ulceration • Rapid enlargement Unstable aneurysm (Impending rupture)
  33. 33. Inspection 5- Aneurysms Thin, shiny skin Unstable aneurysm (Impending rupture)
  34. 34. Inspection 5- Aneurysms Aneurysms with ulceration (arrows; depigmentation with early skin break-down). Unstable aneurysm (Impending rupture)
  35. 35. Inspection 6- Arm Elevation Test Inflow Outflow
  36. 36. Inspection 6- Arm Elevation Test
  37. 37. Inspection 6- Arm Elevation Test Normally: Collapse
  38. 38. Inspection 6- Arm Elevation Test Outflow Stenosis Normally: Collapse
  39. 39. Inspection 7- Central vein stenosis
  40. 40. Inspection 7- Central vein stenosis
  41. 41. Inspection 7- Central vein stenosis Early, subcutaneous collaterals
  42. 42. How to Examine AVF?
  43. 43. How to Examine AVF? Inflow Outflow Feel to detect outflow or inflow problem 1. AVF Pulse Character 2. AVF Thrill 3. Pulse Augmentation Test 4. Sequential occlusion test 5. Access vs Non Access Limb
  44. 44. How to Examine AVF? Inflow Outflow Feel to detect outflow or inflow problem 1. AVF Pulse Character 2. AVF Thrill 3. Pulse Augmentation Test 4. Sequential occlusion test 5. Access vs Non Access Limb
  45. 45. Palpation 1-AVF Pulse Character
  46. 46. Palpation 1-AVF Pulse Character Outflow Stenosis Hyperpulsatile, Water-hammer
  47. 47. Palpation 1-AVF Pulse Character Outflow Stenosis Inflow Stenosis Hypopulsatile, Feeble, FlatHyperpulsatile, Water-hammer
  48. 48. Palpation 2-AVF Thrill Normally: Continues Thrill
  49. 49. Palpation 2-AVF Thrill Abnormally: Discontinues Thrill (Systolic only) Outflow Stenosis Strong, Localized Normally: Continues Thrill
  50. 50. Palpation 2-AVF Thrill Outflow Stenosis Strong, Localized Weak, not localized Inflow Stenosis Abnormally: Discontinues Thrill (Systolic only) Normally: Continues Thrill
  51. 51. Palpation 2-AVF Thrill Examine thrill from anastomosis all way to chest wall Outflow Stenosis Strong, Localized Weak, not localized Inflow Stenosis Abnormally: Discontinues Thrill (Systolic only) Normally: Continues Thrill
  52. 52. How to Examine AVF? Inflow Outflow Feel to detect outflow or inflow problem 1. AVF Pulse Character 2. AVF Thrill 3. Pulse Augmentation Test 4. Sequential occlusion test 5. Access vs Non Access Limb
  53. 53. How to Examine AVF? Inflow Outflow Feel to detect outflow or inflow problem 1. AVF Pulse Character 2. AVF Thrill 3. Pulse Augmentation Test 4. Sequential occlusion test 5. Access vs Non Access Limb
  54. 54. Palpation 3-Pulse Augmentation Test
  55. 55. Palpation 3-Pulse Augmentation Test Normally: Pulse augmentation, Absence of Thrill
  56. 56. Palpation 3-Pulse Augmentation Test Normally: Pulse augmentation, Absence of Thrill No Pulse augmentation
  57. 57. Palpation 3-Pulse Augmentation Test No Pulse augmentation, No thrill = Inflow stenosis No Pulse augmentation
  58. 58. Palpation 3-Pulse Augmentation Test No Pulse augmentation, No thrill = Inflow stenosis No Pulse augmentation, Normal thrill = Accessory Vein(s) No Pulse augmentation
  59. 59. Palpation 3-Pulse Augmentation Test No Pulse augmentation, No thrill = Inflow stenosis No Pulse augmentation, Normal thrill = Accessory Vein(s) Sequential occlusion test No Pulse augmentation
  60. 60. Palpation 4-Sequential occlusion test To detect the level of accessory veins Still No Pulse augmentation, Normal thrill Augmentation, No thrill = Level of accessory vein detected
  61. 61. How to Examine AVF? Inflow Outflow Feel to detect outflow or inflow problem 1. AVF Pulse Character 2. AVF Thrill 3. Pulse Augmentation Test 4. Sequential occlusion test 5. Access vs Non Access Limb
  62. 62. How to Examine AVF? Inflow Outflow Feel to detect outflow or inflow problem 1. AVF Pulse Character 2. AVF Thrill 3. Pulse Augmentation Test 4. Sequential occlusion test 5. Access vs Non Access Limb
  63. 63. Palpation 5-Access vs Non Access Limb Test Suspected Abnormality Temperature Warm + swelling = infection Cold = Steal syndrome Grip strength Steal syndromeRange of motion Sensory loss
  64. 64. How to Examine AVF?
  65. 65. How to Examine AVF?
  66. 66. Auscultation 1-Bruit Normally: Continues Thrill
  67. 67. Auscultation 1-Bruit Abnormally: Discontinues Thrill (Systolic only) Outflow Stenosis High Pitched, Loud Normally: Continues Thrill
  68. 68. Auscultation 1-Bruit Continues Thrill Discontinues Thrill (Systolic only) Outflow Stenosis Inflow Stenosis High Pitched, Loud Low Pitched, Quiet Abnormally: Discontinues Thrill (Systolic only) Normally: Continues Thrill
  69. 69. Auscultation 1-Bruit Continues Thrill Discontinues Thrill (Systolic only) Outflow Stenosis Inflow Stenosis High Pitched, Loud Low Pitched, Quiet Auscultate AVF from anastomosis all way to chest wall Abnormally: Discontinues Thrill (Systolic only) Normally: Continues Thrill
  70. 70. Auscultation 2-Heart For early detection of newly formed murmurs (?? infective endocarditis)
  71. 71. Gawad Thank You
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