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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. To get the presentation with full animations and
videos please contact me on
drgawad@gmail.com
For more presentations visit
www.NephroTubeCNE.com

3. Functioning AVF = Patient’s life
=

4. AVF Examination: Dose it matter?
Early Detection of Complications
Semin Dial. 2008;21:269–273.

5. Good AVF Examination
= Early detection of complications
= Saving AVF
= Saving patient’s life
AVF Examination: Dose it matter?
AVF Examination Equation

6. Good AVF Examination
= Early detection of complications
= Saving AVF
= Saving patient’s life
AVF Examination: Dose it matter?
AVF Examination Equation

7. KDOQI 2006
Monitoring the access

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. How to Examine AVF?

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. 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. Inspection
1- Vascular Access Scar
Anatomy of Upper Extremity Vessels

13. Inspection
1- Vascular Access Scar
Radiocephalic AVF

14. Inspection
1- Vascular Access Scar
Snuff-box AVF

15. Inspection
1- Vascular Access Scar
Brachiocephalic AVF

16. Inspection
1- Vascular Access Scar
Transposed Basilic Vein AVF

17. Inspection
1- Vascular Access Scar
Transposed Forearm Cephalic Vein AVF

18. Inspection
1- Vascular Access Scar
Transposed Forearm Basilic Vein AVF

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. 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. Inspection
2- Signs of Infection/Inflammation
± Pain/Fever

22. Inspection
2- Signs of Infection/Inflammation
± Pain/Fever

23. Inspection
2- Signs of Infection/Inflammation
Skin Rash

24. Inspection
3- Hematoma

25. Inspection
4- Signs of Ischemia (Steal Syndrome)

26. Fingers are blue and cold
Hand pain rest/exercise
Paresthesia
Inspection
4- Signs of Ischemia (Steal Syndrome)

27. Ulcers
Inspection
4- Signs of Ischemia (Steal Syndrome)

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. 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. 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. Inspection
5- Aneurysms Stable Aneurysm

32. Inspection
5- Aneurysms
• Thin, shiny skin
• Prolonged leaking
• Ulceration
• Rapid enlargement
Unstable aneurysm
(Impending rupture)

33. Inspection
5- Aneurysms
Thin, shiny skin
Unstable aneurysm
(Impending rupture)

34. Inspection
5- Aneurysms
Aneurysms with ulceration
(arrows; depigmentation
with early skin break-down).
Unstable aneurysm
(Impending rupture)

35. Inspection
6- Arm Elevation Test
Inflow
Outflow

36. Inspection
6- Arm Elevation Test

37. Inspection
6- Arm Elevation Test
Normally:
Collapse

38. Inspection
6- Arm Elevation Test
Outflow
Stenosis
Normally:
Collapse

39. Inspection
7- Central vein stenosis

40. Inspection
7- Central vein stenosis

41. Inspection
7- Central vein stenosis
Early, subcutaneous collaterals

42. How to Examine AVF?

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. 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. Palpation
1-AVF Pulse Character

46. Palpation
1-AVF Pulse Character
Outflow Stenosis
Hyperpulsatile, Water-hammer

47. Palpation
1-AVF Pulse Character
Outflow Stenosis Inflow Stenosis
Hypopulsatile, Feeble, FlatHyperpulsatile, Water-hammer

48. Palpation
2-AVF Thrill
Normally:
Continues Thrill

49. Palpation
2-AVF Thrill
Abnormally: Discontinues Thrill (Systolic only)
Outflow Stenosis
Strong, Localized
Normally:
Continues Thrill

50. Palpation
2-AVF Thrill
Outflow Stenosis
Strong, Localized Weak, not localized
Inflow Stenosis
Abnormally: Discontinues Thrill (Systolic only)
Normally:
Continues Thrill

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. 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. 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. Palpation
3-Pulse Augmentation Test

55. Palpation
3-Pulse Augmentation Test
Normally: Pulse augmentation,
Absence of Thrill

56. Palpation
3-Pulse Augmentation Test
Normally: Pulse augmentation,
Absence of Thrill
No Pulse augmentation

57. Palpation
3-Pulse Augmentation Test
No Pulse augmentation,
No thrill
= Inflow stenosis
No Pulse augmentation

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. 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. 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. 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. 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. 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. How to Examine AVF?

65. How to Examine AVF?

66. Auscultation
1-Bruit
Normally:
Continues Thrill

67. Auscultation
1-Bruit
Abnormally: Discontinues Thrill (Systolic only)
Outflow Stenosis
High Pitched, Loud
Normally:
Continues Thrill

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. 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. Auscultation
2-Heart
For early detection of newly formed
murmurs
(?? infective endocarditis)

73. Gawad
Thank You