Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.

Doppler ultrasound of A-V access for hemodialysis

78 486 vues

Publié le

Publié dans : Santé & Médecine, Business
  • Sharpen your mind with brain pill. learn more info.. ▲▲▲ https://bit.ly/2GEWG9T
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD FULL eBOOK INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookeBOOK Crime, eeBOOK Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD FULL eBOOK INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookeBOOK Crime, eeBOOK Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici

Doppler ultrasound of A-V access for hemodialysis

  1. 1. Doppler US of A-V access for hemodialysisSamir Haffar M.D.Department of Internal MedicineAl-Mouassat University Hospital – Damascus – Syria
  2. 2. Doppler US of A-V access for hemodialysis Normal Doppler US of upper extremity Preoperative US vascular mapping Type of A-V access for hemodialysis Normal Doppler US of A-V access for hemodialysis Routine surveillance in asymptomatic patients Complications of A-V access for hemodialysis Conclusion
  3. 3. Doppler US of A-V access for hemodialysis Normal Doppler US of upper extremity Preoperative US vascular mapping Type of A-V access for hemodialysis Normal Doppler US of A-V access for hemodialysis Routine surveillance in asymptomatic patients Complications of A-V access for hemodialysis Conclusion
  4. 4. Anatomy of aortic arch & subclavian arteryRight SCA originates from innominate (brachiocephalic) arteryLeft SCA originates directly from aortic archSCA has several branches: VA & mammary (internal thoracic) arteryThrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, 2nd edition, 2005.
  5. 5. Arterial anatomy of upperextremityThrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, 2nd edition, 2005.LSA Common origin with CCA from ABA High bifurcation of brachial arteryRA High origin from axillary arteryUA High origin from axillary arteryAnatomical variations
  6. 6. Normal brachial arteryDeklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.Diameter from intima to intimaPerpendicular to arterial wallSagittal US scan Sagittal color DopplerHomogenous velocitiesGood visualisation of arterial bords
  7. 7. Normal duplex US of peripheral arteriesHigh resistance flowNormal brachial arteryTriphasic flow
  8. 8. Venous anatomy of upper extremityDeklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.Superficial systemBasilic vein Drains medial side of upper limbPenetrates fascia in lower arm to join brachial veinCephalic vein Drains lateral side of upper limbJoin axillary vein in infraclavicular region
  9. 9. Normal venous flow Spontaneity Spontaneous flow without augmentation Phasicity Flow changes with respiration Compression Transverse plane Augmentation Compression distal to site of examinationPatency below site of examination Valsalva Deep breath, strain while holding breathPatency above site of examination
  10. 10. Vein compressibilityKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.CompressionRegular thin wallDiameter: 5.2 mmBasilic veinVein fully compressedBasilic vein
  11. 11. Color & pulsed Doppler of cephalic veinMihmanli I et al. J Ultrasound Med 2001 ; 20 : 217 – 222.Normal lumen blushNormal respiratory phasicity
  12. 12. Doppler US of A-V access for hemodialysis Normal Doppler US of upper extremity Preoperative US vascular mapping Type of A-V access for hemodialysis Normal Doppler US of A-V access for hemodialysis Routine surveillance in asymptomatic patients Complications of A-V access for hemodialysis Conclusion
  13. 13. Doppler US criteria for good outcomeEvaluation of nondominant arm first• Peripheral arteries Diameter at least 1.6 mmHyperemic responsePatent palmar arch (US Allen test)• Peripheral veins AVF: ≥ 2 mm without tourniquet≥ 2.5 mm with tourniquetGraft: at least 4 mm with tourniquet• Central veins Respiratory phasicity“indirect assessment” Transmitted cardiac pulsatilityValsalva (flow drops to baseline)Silva MB et al. J Vasc Surg 1998 ; 27 : 302 – 308.Robbin ML et al. Radiology 2000 ; 217 : 83 – 88.
  14. 14. Measurement of artery diameterFerring M et al. Nephrol Dial Transplant 2008 ; 23 : 1809 – 1815.Radial artery (M mode)Point of artery insonated over timeDiameter at peak systole: 2.1 mmDiameter in diastole: 2 mmFrom intima to intimaPerpendicular to arterial wallDiameter: 2.2 mmRadial artery (B mode)Blooming effect
  15. 15. Arterial hyperemic responseUseful to predict risk of arterial stealWiese P et al. Nephrol Dial Transplant 2004 ; 19 : 1956 – 1963.Clenched fist (3 min) : high-resistance flow (triphasic)Released fist : low-resistance flow (monophasic) & RI < 0.70Failure of such response regarded as CI to AVF
  16. 16. Pourcelot’s resistance indexResistance Index (RI): Systolic – End Diastolic / Systolic
  17. 17. Color Doppler of the palmar archReversed flowFlow via ulnar arteryOcclusion of radial arterywhile imaging archColor Dopplerof palmar arteryMozersky DJ et al. Am J Surg. 1973 ; 126 : 810 – 812.Levitov A et. Critical care ultrasonography. McGraw-Hill Medical, NY, USA, 2009.US may may improve accuracy of Allen’s testFirst reported in 1973
  18. 18. Radial artery at wristSegmental occlusive lesionsCalcified wall with marked shadowingParmley MC et al. Am J Surg 2002 ; 184 : 568 – 572.
  19. 19. SpontaneityPhasicityCompressibilityLumen echogenicityWall irregularityDiameterVeins examined from wrist to distal end of clavicleMihmanli I et al. J Ultrasound Med 2001 ; 20 : 217 – 222.
  20. 20. Cephalic vein wallMarked wall irregularityWall thickening especially on posterior sideMihmanli I et al. J Ultrasound Med 2001 ; 20 : 217 – 222.
  21. 21. Robbin ML et al. Radiology 2000 ; 217 : 83 – 88.Normal caliber of SCV50% stenosis of BCVCorresponding venogramAbnormal respiratory phasicityNo decrease to baseline with inspirationDoppler US of patent SCVCentral vein stenosisPaget Schroetter syndrome
  22. 22. Central vein stenosisPaget Schroetter syndromeRobbin ML et al. Radiology 2000 ; 217 : 83 – 88.Doppler US of patent SCVAbnormal respiratory phasicityMonophasic flowSuspicion of CV stenosis/occlusionCorresponding venogramSevere stenosis of BCVat its junction with SMVSecond channel adjacent to stenosisRecognition of central vein stenosis is CI to use of that extremity
  23. 23. Upper extremity arterial mappingBrown PWG. Eur J Vasc Endovasc Surg 2006 ; 31 : 64 – 69.
  24. 24. Upper extremity vein mappingCephalic veinMendes RR et al. J Vasc Surg 2002 ; 36 : 460 – 3.Eight representative measurement sites of CV:Diameter with & without tourniquetDepth from skin
  25. 25. Preoperative vascular mappingRobbin ML et al. Radiology 2000 ; 217 : 83 – 88.50-year-old man with nonpalpable cephalic vein in wristScheduled to receive forearm graftTransverse cephalic veinRadial arteryat wrist3.7 mmWrist2.8 mmMiddle forearm2.7 mmAntecubital area2.8 mmAdequate diameters for AVF placement
  26. 26. Preoperative vascular mappingDuplex sonography of upper limb arteries & veinsperformed in conjunction with clinical examination in allpatients for whom an AVF is being considered* National Kidney Foundation’sKidney Disease Outcomes Quality InitiativeNational Kidney Foundation. Am J Kidney Dis 2006 ; 48(Suppl. 1) : S1 – S322.Recommendations of NKF-KDOQI*
  27. 27. Doppler US of A-V access for hemodialysis Normal Doppler US of upper extremity Preoperative US vascular mapping Type of A-V access for hemodialysis Normal Doppler US of A-V access for hemodialysis Routine surveillance in asymptomatic patients Complications of A-V access for hemodialysis Conclusion
  28. 28. Brescia-Cimino A-V fistulaBrescia MJ, Cimino JE, Appel K, et al. N Engl J Med 1966 ; 275 : 1089 – 92.Side of artery to end of veinAt anatomical snuffbox or wristSurgeons who invented AVF:Brescia, Cimino, & AppelMost commonly used
  29. 29. Types of Arterio-Venous FistulaFinlay DE et al. RadioGraphics 1993 ; 13 : 983 – 999.Side of artery to side of veinEnd of artery to side of veinSide of artery to end of veinBrescia-Cimino AVFEnd of artery to end of vein
  30. 30. Types of A-V grafts (PTFE – Polyurethane )Curr Probl Surg 2011 ; 48 : 443 – 517.ForearmBarachial artery to brachial vein“Loop graft”Upper armRadial artery to axillary vein“Straight graft”
  31. 31. A-V access for hemodialysis in preferential orderType Description Forearm AVF Radial artery to cephalic veinRadial artery to basilic veinRadial artery to other suitable vein (transposition*)AVF placement preferable to graft placementNondominant arm is preferred site for access placement* Transposition AVFs placed in veins other than cephalic veinRobbin ML et al. Radiology 2000 ; 217 : 83 – 88. Upper arm AVF Brachial artery to cephalic veinBrachial artery to basilic veinBrachial artery to other suitable vein (transposition*) Forearm graft Brachial artery & antecubital vein (loop graft) Upper arm graft Brachial artery & high brachial or basilic vein Thigh graft CFA to CFV
  32. 32. Distribution of AVF & graft use in Europe& the United StatesHuijbregts HJ et al. Eur J Vasc Endovasc Surg 2006 ; 31 : 284 – 287.Following percentiles of each distribution provided forthe 10th, 25th, 50th (median), 75th, & 90th percentiles
  33. 33. Radio-cephalic fistula at wristMA (8 prospective & 30 retrospective studies – 4579pts)High primary failure rateModerate patency rates at 1 year of follow-up* Sidawy AN et al. J Vasc Surg 2002 ; 35 : 603 – 610.Rooijens PP et al. Eur J Vasc Endovasc Surg 2004 ; 28 : 583 – 589.• Primary failure rate*Thrombosis or failure to mature at 6 weeks15.3% (95% CI: 12.7 – 18.3%) [from 10% to 30%]• Primary patency rate at 1 year of follow-up*From creation until intervention to maintain or re-establishpatency, thrombosis or time of patency measurement62.5% (95% CI: 54.0 – 70.3%)
  34. 34. Doppler US of A-V access for hemodialysis Normal Doppler US of upper extremity Preoperative US vascular mapping Type of A-V access for hemodialysis Normal Doppler US of A-V access for hemodialysis Routine surveillance in asymptomatic patients Complications of A-V access for hemodialysis Conclusion
  35. 35. Doppler US of A-V access for hemodialysisAbundant gel & minimal pressure on skinLongitudinal & transverse scan from feeding artery to anastomosisLongitudinal & transverse scan from draining vein as far as possiblePerivascular space: functional stenosis from abscess, hematoma, seromaEdenberg Jan et al. Tidsskr Nor Legeforen nr. 2009 ; 129 : 1635 – 8.
  36. 36. Normal Doppler US in AVFs• Feeding artery Monophasic flowLarge diastolic component• Anastomosis Perivascular tissue vibrationVery turbulent flow over long stretch• Draining vein Pulsatile flow (arterialized vein)• Volume flow > 500 mL/minDilatation of feeding artery & draining veinafter several years of useSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
  37. 37. Normal Doppler US in AVFsBrachio-basilic fistulaKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.Brachial arteryMonophasic flowLarge diastolic componentBrachio-basilic fistulaArterialized vein
  38. 38. Doppler US of polyurethane graftThree-layered material – Cannulation within 24 hWiese P et al. Nephrol Dial Transplant 2003 ; 18 : 1397 – 1400.1 year follow-upSignal from whole graftEarly post-operativeStrong reflection from graft1 year follow-upSignal at site of single cannulation1 year follow-upSignal at sites of repeat cannulation
  39. 39. Volume = Cross-sectional area . Mean velocity . 60(mL/min) (cm2) (cm/sec)Cross-sectional area (cm2): π d2 / 4d: diameterMeasurement of flow volumeHoskins P et al. Diagnostic US: physics and equipment.Cambridge university press, Cambridge, UK. 2nd ed, 2010.
  40. 40. Place of flow volume measurement• Arteriovenous fistulaFeeding artery Brachial artery in middle upper armRecommended by some authorsWithin fistula Turbulent flow (spectral broadening)Draining vein Abrupt change in diameter in older AFVChanges in lumen shape (elliptical)Recommended by other authors• GraftInvestigated along the entire accessSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
  41. 41. Measurement of flow volume /Feeding arteryDiameter perpendicular to axisSample volume across width of vesselSample volume in same site of diameter measurementCorrect estimation of angleTAMV: 3 – 5 cardiac cyclesDeklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.
  42. 42. Measurement of flow volume in feeding arteryDeklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.Normal flow in distal radial arteryFlow volume (fistula open) – Flow volume (fistula closed)Normal volume in upper limb: 100 mL/min (neglected)Reversed flow in distal radial arteryFlow volume (proximal a) + Flow volume (distal a)
  43. 43. Sources of error in volume measurement• Diameter Measuring accuracy (blooming effect)Main source Assumption of circular cross-sectionVariation during cardiac cycleVariation during respiration (veins)• Doppler angle As small as possible & < 60Box steering & transducer shifting• Mean velocity Setting of transmitted & received gainOver or underestimationSchäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2nd edition, 2011.
  44. 44. Error percentage in volume measurements& vessel diameterSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.Errors ranging from 0.2 to 1.0 mm
  45. 45. Doppler phenomenon?Doppler shift frequency (fd): ft – frThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.ftfr∆ F = 2 F0 V Cos Ө / C
  46. 46. Angle of insonation & Doppler effectKim Min Ju et al. Curr Probl Diagn Radiol 2009 ; 38 : 53 – 60.Angles between 30 to 60 usually used for Doppler acquisition
  47. 47. Error percentage in velocity measurements& angle of insonationAngle of insonation > 60 should not be used
  48. 48. Doppler angle correction in AVFPieturaa R et al. Eur J Radiol 2005 ; 55 : 113 – 119.
  49. 49. Adjusting spectral Doppler gainGain setting too lowCorrect gain settingGain setting too highKruskal JB et al.RadioGraphics 2004 ; 24 : 657 – 675.
  50. 50. Tips for volume flow measurement• Avoid significant turbulence (circular flow)• Accurate determination of vessel diameter• Adequate insonation angle (≤ 60⁰)• Sample volume covers entire area of vessel• No significant diversion of blood through accessory vein• Flow determined in feeding artery if complex vein anatomy• Various algorithms used by manufacturers (by up to 30%)Gelbfish GA. Tech Vasc Interventional Rad 2008 ; 11 : 156 – 166.Slight errors in one parameter lead to erroneous numbers
  51. 51. Interpretation of fistula flow volumeA-V access for hemodialysis Flow volume (mL/min)Normal valueForearm fistulaUpper arm fistula600 – 800900 – 1200Schäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.Mature fistula ≥ 500High risk of occlusionAVFGraft< 300< 650High-output cardiac failureAdultChildren> 3.000> 700
  52. 52. Doppler US of A-V access for hemodialysis Normal Doppler US of upper extremity Type of A-V access for hemodialysis Preoperative US vascular mapping Normal Doppler US of A-V access for hemodialysis Routine surveillance in asymptomatic patients“Mature fistula” Complications of A-V access for hemodialysis Conclusion
  53. 53. Causes of immature fistula Stenosis at or near the fistulaAngioplasty – surgical revision One or more accessory veinsLigation Deep draining veinFistula surgically placed in more superficial soft tissuesImmature fistula can be converted into usable fistulawith correction of underlying problemSingh P et al. Radiology 2008 ; 246 : 299 – 305.
  54. 54. Sonographically mature fistulaDoppler US exam 6 – 8 weeks after surgery• AP diameter of draining vein At least 4 mm• Distance from skin to anterior wall Less than 5 mm• Flow volume At least 500 mL/minRobbin ML. Radiology 2002 ; 225 : 59 – 64.Singh P et al. Radiology 2008 ; 246 : 299 – 305.Should meet the 3 following criteriaCriteria different from clinically mature fistula
  55. 55. Doppler US for routine surveillance• AP diameter of draining vein in transverse scanUsually thin wall: cursors within vein walls• Distance from skin to anterior wall of draining vein• Veins branching off within first 10 cm of anastomosisAP diameter & distance from anastomosis• Flow volume Straight segment of artery or veinRepeat 3 – 5 times with averageSingh P et al. Radiology 2008 ; 246 : 299 – 305.
  56. 56. Mature fistula/Good diameter & depthAnteroposterior diameter of draining vein: 6 mmDistance from skin surface to anterior vein wall: 4.8 mmSingh P et al. Radiology 2008 ; 246 : 299 – 305.Transverse US of draining vein
  57. 57. Mature fistula/Good flow volumeBrachio-basilic fistulaKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.Diameter: 7.9 mmTAMV: 93.2 cm/sec over 3 cardiac cyclesFlow volume: 2.741 mL/min
  58. 58. Immature fistula/Large accessory veinSingh P et al. Radiology 2008 ; 246 : 299 – 305.Large accessory vein which may limit maturation of fistulaSearch for all accessory veins within first 10 cm of anastomosisTransverse US of draining vein
  59. 59. Immature fistula/Small & deep veinDraining veinVein too small (3.1 mm)Vein too deep (7.6 mm)Singh P et al. Radiology 2008 ; 246 : 299 – 305.
  60. 60. Immature fistula/Low flow volumeRadio-cephalic fistulaLeft radial arteryFlow volume : 86 mL/minLeft cephalic veinFlow volume : 130 mL/minKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
  61. 61. Routine surveillance in asymptomatic patientsNo RCTs of Doppler surveillance in this settingRoutine surveillance by combination of clinical examination,direct flow measurement, & duplex US should be performedWhen stenosis > 50% is accompanied by hemodynamicor clinical abnormalities, angioplasty is recommended* National Kidney Foundation’sKidney Disease Outcomes Quality InitiativeNational Kidney Foundation. Am J Kidney Dis 2006 ; 48(Suppl. 1) : S1 – S322.Recommendations of NKF-KDOQI*
  62. 62. Doppler US of A-V access for hemodialysis Normal Doppler US of upper extremity Type of A-V access for hemodialysis Preoperative US vascular mapping Normal Doppler US of A-V access for hemodialysis Routine surveillance in asymptomatic patients Complications of A-V access for hemodialysis Conclusion
  63. 63. Complications of A-V access for hemodialysis Stenosis & occlusion Aneurysm & pseudoaneurysm Arterial steal syndrome High-output cardiac failureHematomaSeromaLymphocele Infected & non-infected collections
  64. 64. Mechanisms & sites of stenosis• AVF Feeding artery Atherosclerosis (SC, axillary)• Graft Intimal hyperlplasia (shear stress)Anastomosis between graft & veinDraining vein Intimal hyperplasia (valves)Puncture-induced dissectionProximal – distalAnastomosis Turbulence (most common)Central veins Catheters (SC, axillary)Schäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
  65. 65. Venous stenosis from intimal hyperplasiaEdenberg Jan et al. Tidsskr Nor Legeforen nr. 2009 ; 129 : 1635 – 8.Venous stenosis 3 cm from anastomosisPower Doppler ultrasound
  66. 66. US Doppler criteria for significant stenosis(> 50 % diameter reduction)• Us criteria Percentage of diameter reduction• Color criteria Pronounced aliasing at site of stenosis• Duplex criteria PSV ratioPSV: should not be interpreted in isolation
  67. 67. Measurement of luminal diameter reductionEdenberg Jan et al. Tidsskr Nor Legeforen nr. 2009 ; 129 : 1635 – 8.Wiese P et al. Nephrol Dial Transplant 2004 ; 19 : 1956 – 1963.Residual lumen 1.1 mmOriginal lumen 5.1 mm78 % diameter stenosisOriginal lumen – Residual lumenx 100% of diameter stenosisOriginal lumen=
  68. 68. Color criteria of significant stenosisPronounced aliasing at site of stenosisJunction of basilic & axillary vein
  69. 69. Duplex criteria for significant stenosis (> 50%)• Direct signsFeeding artery PSV ratio ≥ 2Anastomosis PSV ratio ≥ 3 – PSV > 400 cm/sec*Draining vein PSV ratio ≥ 3 – PSV > 300 cm/sec*• Indirect signsFlow volume < 250 mL/minProximal High-resistance flow (RI > 0.70)Distal Delayed systolic upstroke* Flow volume adequate for hemodialysisSchäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2nd edition, 2011.
  70. 70. PSV ratioRobbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.Proximal: 2 cm proximal to stenosisStenosis: same Doppler angle if possible
  71. 71. Significant stenosis of AVF at anastomosisRadio-cephalic fistulaPSV ratio: 3.4Arterio-venous anastomosisPSV: 438 cm/sRadial arteryPSV: 130 cm/sGrogan J et al. J Vasc Surg 2005 ; 41 : 1000 – 6.
  72. 72. Proximal venous stenosisKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.Pronounced aliasing at site of stenosisPeak Systolic Velocity: 610 cm/sCephalic vein – Mid upper arm
  73. 73. Distal venous stenosisDeklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.Pronounced aliasing at site of stenosisPeak Systolic Velocity: 340 cm/sJunction of basilic & axillary vein
  74. 74. Stenosis of graft insertion on veinDeklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.Rail aspect of the graftAliasing on color DopplerPeak Systolic Velocity : 400 cm / s
  75. 75. Pseudo-diagnosis of significant stenosisKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.PSV: 570 cm/secBrachio-basilic fistulaBrachial arteryPSV: 350 cm/secVolume flow:1.1 L/minHigh inflowBasilic veinPSV: 175 cm/secVolume flow:1.8 L/minHigh outflowHigh PSV in anastomosis due to high flow volume & large vessels
  76. 76. Occlusion of brachiocephalic fistulaTriphasic waveformRI = 1 (thrombosed fistula)Brachial arteryOcclusion of fistulaThrombus within draining veinBrachio-cephalic fistulaKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
  77. 77. Thrombosis in draining vein of AVFEdenberg Jan et al. Tidsskr Nor Legeforen nr. 2009 ; 129 : 1635 – 8.Pieturaa R et al. Eur J Radiol 2005 ; 55 : 113 – 119.Complete thrombosis Partial thrombosis
  78. 78. Complications of A-V access for hemodialysis Stenosis & occlusion Aneurysm & pseudoaneurysm Arterial steal syndrome High-output cardiac failureHematomaSeromaLymphocele Infected & non-infected collections
  79. 79. AneurysmDevelops in AVF functioning for many years• Good function Lumen not filled with thrombusIntact skin• Intervention Intra-luminal thrombusrarely needed Compromise of overlying skinSteadily & rapidly enlargedObstructive kinks• Operation Proximal A-V access of arterialized veinProsthetic graftPadberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.
  80. 80. Diffuse aneurysmal dilationSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.Secondary to wall degeneration or downstream stenosisFeeding arteryDraining veinAnastomosis
  81. 81. True venous aneurysmDiffuse aneurysmal dilationBourquelot P et al. Nephrol Ther 2009 ; 5 : 239 – 248.Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.Raise concern from the staffRadio-cephalic AVF Color Doppler US
  82. 82. Pseudoaneurysm• Incidence 2 – 10 % during functional life of graftLess frequent in AVF• Doppler US Color Doppler: “yin -yang pattern”Pulsed Doppler: “to-and-fro waveform”Perianeurysmal fluid collection suggest infection• Location Puncture site Observation if small & stableTreatment if expandingAnastomotic Generally requires surgeryInfection is common causePadberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.
  83. 83. Anastomotic pseudoaneurysm on A-V graftKabalci YM et al. Transplant Proc 2006 ; 38 : 2816 – 2818.Brachio-basilic graft 2 months agoAnastomotic pseudoaneurysm of graft is rare
  84. 84. PseudoaneurysmColor Doppler“yin -yang pattern”Pulsed Doppler“to-and-fro waveform”Schäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
  85. 85. Perivascular space with pulsatile flowBidirectional blood flowTypical “yin-yang sign”Pseudoaneurysm of radial arteryColor duplex US Thrombin injection under US controlComplete thrombosis afterthrombin injectionCarrafiello G et al. Injury Extra 2006 ; 37 : 78 – 81.
  86. 86. Complications of A-V access for hemodialysis Stenosis & occlusion Aneurysm & pseudoaneurysm Arterial steal syndrome High-output cardiac failureHematomaSeromaLymphocele Infected & non-infected collections
  87. 87. HematomaKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.AV access punctured thrice weekly for hemodialysisSerial examinations to monitor evolution of hematoma
  88. 88. Complications of A-V access for hemodialysis Stenosis & occlusion Aneurysm & pseudoaneurysm Arterial steal syndrome High-output cardiac failureHematomaSeromaLymphocele Infected & non-infected collections
  89. 89. Radial artery stealFinlay DE et al. RadioGraphics 1993 ; 13 : 983 – 999.Ulnar artery flow contributes to fistula flow via palmar archesRetrograde flow in distal radial artery
  90. 90. Arterial steal syndromeClinical diagnosis – Incidence (1 – 4 %)• Risk factor Brachial arterial, DM, female gender• Symptoms Steal phenomenon Silent (70% of RC-AVF)Steal syndrome Mild: pain during dialysisSevere: rest pain, ulcerationCommon cause of neuropathy• Doppler US Reversed flow: complete – only in diastoleDynamic study: gentle compression of AVF• Treatment Ligation, banding, reroutingPadberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.
  91. 91. Radial arterial stealFrequent in asymptomatic patientsWiese P et al. Nephrol Dial Transplant 2004 ; 19 : 1956 – 1963.Fistula supplied by proximal radial artery (red, antegrade flow)Fistula supplied by distal radial artery (blue, retrograde flow)
  92. 92. Reversed flow in distal RA after AVFGoldfeld M et al. AJR 2000 ; 175 : 513 – 516.Reversed flow during entire cardiac phase
  93. 93. Arterial steal syndromeRadial-cephalic fistulaYilmaz C et al. AJR 2009 ; 193 : W567.RA distal to anastomosisAntegrade flow during systoleRetrograde flow during diastoleGentle compression of fistulaRestoration of antegrade flowElevated systolic flowElevated diastolic flowBidirectional flow
  94. 94. Hand ischemia in A-V access for hemodialysis• Arterial steal syndrome Most common• Proximal arterial stenosis Overlooked• Atherosclerosis in hand & forearm Arteriography• Regional venous hypertension• Emboli of thrombosed A-V access Doppler USPadberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.
  95. 95. Digital ischemia from emboli of thrombosed AVF7 reported cases in the literatureJournet J et al. Néphrologie & Thérapeutique 2010 ; 6 : 121 – 124.Digital ischemia4 fingers of right handRegression of ishemia6 mth after operationPartial thrombosisof RC-AVF
  96. 96. Complications of A-V access for hemodialysis Stenosis & occlusion Aneurysm & pseudoaneurysm Arterial steal syndrome High-output cardiac failureHematomaSeromaLymphocele Infected & non-infected collections
  97. 97. High-output cardiac failureRare &unusual complication• Symptom Symptoms of right heart failureNicoladoni-Branham sign: ↓ PR after AVF occlusion• Diagnosis Flow volume > 3 L/minFlow volume/cardiac output ≥ 30% (screening)Cardiac output > 2.3 L/min/m2Sine qua none: improvement after treatment• Treatment Ligation: sacrifice of accessBanding: more attractive optionPadberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.
  98. 98. Conclusion• Doppler uplex US should be interpreted in conjunction withclinical findings including adequacy of dialysis• Results should be discussed within multidisciplinary team:Nephrologist, vascular surgeon, & interventional radiologist• Stenosis in early postop period interpreted with cautionThey may be secondary to transient edema• Duplex sonography is central to prevention, detection, andmanagement of complicationsKerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
  99. 99. References1. Kerr SF et al. Duplex sonography in the planning & evaluation ofarteriovenous fistula for hemodialysis Clin Radiol 2010;65:744-749.2. Wiese P et al. Color Doppler ultrasound in dialysis access. NephrolDial Transplant 2004;19:1956-1963.3. Padberg FT et al. Complications of arteriovenous hemodialysisaccess: recognition and management. J Vasc Surg 2008;48:55S-80S.4. Konner K et al. The arteriovenous fistula. J Am Soc Nephrol 2003;14:1669-1680.5. Pieturaa R et al. Color Doppler ultrasound assessment of well-functioning mature arteriovenous fistulas for haemodialysis access.Eur J Radiol 2005;55:113-119.6. Deklunder G et al. Exploration des vaisseaux du membre supérieur:Doppler et échotomographie. EMC-Radiologie 2004;1:632-646.
  100. 100. Thank You

×