Evaluation of Dialysis Access

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VASCULAR TECHNOLOGY PROFESSIONAL PERFORMANCE GUIDELINES Evaluatin f Dialysis Access This Guideline was prepared by the Prfessinal Guidelines Subcmmittee f the Sciety fr Vascular Ultrasund (SVU) as a

1 VASCULAR TECHNOLOGY PROFESSIONAL PERFORMANCE GUIDELINES Evaluatin f Dialysis Access This Guideline was prepared by the Prfessinal Guidelines Subcmmittee f the Sciety fr Vascular Ultrasund (SVU) as a template t aid the vascular technlgist/sngrapher and ther interested parties. It implies a cnsensus f thse substantially cncerned with its scpe and prvisins. This SVU Guideline may be revised r withdrawn at any time. The prcedures f SVU require that actin be taken t reaffirm, revise, r withdraw this Guideline n later than three years frm the date f publicatin. Suggestins fr imprvement f this guideline are welcme and shuld be sent t the Executive Directr f the Sciety fr Vascular Ultrasund. N part f this guideline may be reprduced in any frm, in an electrnic retrieval system r therwise, withut the prir written permissin f the publisher. Spnsred and published by: Sciety fr Vascular Ultrasund 4601 Presidents Drive, Suite 260 Lanham, MD Tel.: Fax: E- mail: svuinf@svunet.rg Internet: Cpyright by the Sciety fr Vascular Ultrasund, ALL RIGHTS RESERVED. PRINTED IN THE UNITED STATES OF AMERICA.

2 Evaluatin f Dialysis 2014 Evaluatin f Dialysis Access PURPOSE T determine patency and flw adequacy f a dialysis access fistula r graft and/r identify abnrmalities that may be present. COMMON INDICATIONS Failure t mature n basis f physical examinatin Symptms and signs f disease present Signs f access site malfunctin during dialysis (e.g., lw bld flws, kt/v, recirculatin times, r increased venus pressure) Mass assciated with an AVF/AVG Lss f palpable thrill f AVF/AVG Arm swelling Hand pain, pallr, and/r digital ulceratin (evaluatin fr arterial steal syndrme) Difficult cannulatin by multiple persnnel n multiple attempts CONTRAINDICATIONS AND LIMITATIONS Cntraindicatins fr evaluatin f dialysis access are few; hwever, sme limitatins exist and may include the fllwing: Open wunds n the skin surface Dialysis r shuntgram perfrmed n the same day (flw vlumes may be lwer, cmpressin f access fr pssible steal phenmenn nt recmmended) PATIENT COMMUNICATION Intrduce self t the patient and explain why the evaluatin is being perfrmed and indicate hw much time the exam will take. Explain the prcedure t the patient, taking int cnsideratin the age and mental status f the patient, and ensure that the patient understands the necessity fr each aspect f the evaluatin. Respnd t questins and cncerns abut any aspect f the dialysis access evaluatin. Refer specific diagnstic, treatment r prgnsis questins t the patient's physician. 2 Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America.

3 Evaluatin f Dialysis 2014 PATIENT ASSESSMENT Patient assessment must be perfrmed befre Evaluatin f the Dialysis Access is perfrmed. It includes assessment f the patient s ability t tlerate the prcedure and an evaluatin f any cntraindicatins t the prcedure. The technlgist/sngrapher/examiner shuld: Obtain a cmplete, pertinent histry by interview f the patient r patient s representative and review f the patient s medical recrds whenever pssible. A pertinent histry includes: Review f perative ntes Surgical cnfiguratin Revisins/fistulagrams Current status f dialysis Verify that the requested prcedure(s) crrelates with the patient s clinical presentatin Perfrm a limited r fcused physical exam, including bservatin and lcalizatin f any signs r symptms f access dysfunctin. Determine access patency by the presence f a palpable thrill as well as the strength and cnsistency f thrill thrughut the access (Nte: prminent pulsatility is abnrmal) Prvide a visual inspectin f the limb and access site nting scars, areas f redness, ecchymsis, swelling, dilatatin, and presence f cllateral vessels PATIENT POSITIONING Patient psitining is mst ften supine, with the arm relaxed and extended ut t the side with area t be evaluated clsest t the sngrapher. Fr patient cmfrt, it is helpful t supprt the arm n a bedside table/pillw. Thigh fistula/graft shuld be evaluated in the supine psitin. Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 3

4 Evaluatin f Dialysis 2014 INSTRUMENTATION Use apprpriate duplex instrumentatin, which includes display f bth twdimensinal structure and mtin in real-time and Dppler ultrasnic signal dcumentatin with: Spectral analysis with clr Dppler imaging Imaging carrier frequency f at least 5-10 MHz Dppler carrier frequency f at least 3.0 MHz Digital strage capabilities Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 4

5 Evaluatin f Dialysis 2014 EXAM PROTOCOL Thrughut each examinatin the technlgist/sngrapher/examiner shuld: Observe the sngraphic characteristics f the nrmal and abnrmal tissues, structures, and bld flw t allw necessary adjustments t ptimize exam quality Assess and mnitr the patient s physical and mental status, allwing mdificatins t the prcedure plan accrding t the patient s clinical status Analyze sngraphic findings t ensure that sufficient data is prvided t the physician t direct patient management and render a final diagnsis Dppler is used primarily t dcument patency f the vessels and fistula/graft as well as t identify any areas f stenses in the inflw artery, anastmsis, within the fistula/graft r in the utflw vessels. Dppler spectral analysis is perfrmed in the sagittal plane. All Dppler samples must be perfrmed at an angle f 60 degrees r less with respect t the directin f bld flw. Dppler cursr alignment is recmmended parallel t the vessel walls. Representative wavefrms shuld be recrded. When a stensis is identified, velcities shuld be dcumented in the stensis, prximal t the stensis and distal t the stensis. Flw vlumes shuld be calculated and used t determine fistula maturatin. Functinal disrders can als be identified using flw vlumes. Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 5

6 Evaluatin f Dialysis 2014 ARTERIOVENOUS FISTULA Fllw a standard exam prtcl fr evaluatin f the dialysis access. The standard exam includes assessment f the inflw (afferent) artery, arterial anastmsis, and utflw (efferent) vein. INFLOW ARTERY (afferent) Obtain PSV/EDV at least 2 cm cephalad t the arterial anastmsis PSV shuld be >150 cm/s with lw resistance wavefrm Measure flw vlumes (FV) using system sftware Obtain 2D diameter using B-Mde imaging Optimize spectral windw and btain Time-Averaged Mean Velcity (TAMV) Open sample vlume (slightly wider than vessel) Use a 60-degree angle Measure 2-3 cardiac cycles Nrmal range 800 ml/min t 2500 ml/min ARTERIAL ANASTOMOSIS Obtain spectral Dppler Measure PSV (may be very elevated) and cmpare t the PSV btained in the afferent artery Nte any audible bruit Evaluate with B-Mde imaging (nte any thickening/narrwing) Significant (>50%) anastmtic stensis is indicated when velcity triples cmpared t the afferent artery velcity. OUTFLOW VEIN (efferent) Measure vein diameters (transverse, inner wall-inner wall) Alng curse f vein (prximal, mid, distal) when indicated fr fistula maturatin Mature fistulas have a diameter 4 mm At areas f narrwing Residual lumen f < 2-3 mm indicates significant narrwing Of branches (als nte lcatin in relatin t arterial anastmsis) Measure depth (skin line t tp f vessel) when indicated fr fistula maturatin Mature fistulas have a depth 5 mm. Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 6

7 Evaluatin f Dialysis 2014 Nte any extrinsic findings (hematma, serma, aneurysm, pseudaneurysm) Measure flw vlumes using system sftware (see Inflw Artery sectin fr technique) Select the mid-prtin f the vein in an area that is straight and nntapering Nrmal range 800 ml/min t 2500 ml/min Dppler evaluatin Significant stensis alng the efferent cnduit is indicated when velcity dubles alng cntiguus segments. Obtain spectral Dppler at areas f increased turbulence/narrwing (if apprpriate) PSV > 400 cm/s, EDV >250 cm/s indicates significant utflw vein stensis Measure PSV and FV cephalad t areas f stensis PSV < 150 cm/s and FV < 800 ml/min indicates pr functining f the AV access. Fllw the venus utflw t its rigin Cephalic arch and basilic vein swing pints are cmmn sites fr stensis ARTERIOVENOUS GRAFT Fllw a standard exam prtcl fr evaluatin f the dialysis access. The standard exam includes assessment f the arterial inflw, arterial anastmsis, graft bdy, venus anastmsis, and utflw vein. Measure PSV/EDV at the fllwing lcatins Arterial inflw Arterial anastmsis Graft bdy (mid) Venus anastmsis (cmmn site f stensis) Outflw vein Areas f increased turbulence/narrwing Diagnstic criteria fr significant anastmtic r c Measure flw vlumes Straight AVG Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 7

8 Evaluatin f Dialysis 2014 Mid prtin f the cnduit Lp AVG Arterial side (mid) Venus side (mid) ADDITIONAL IMAGES Stents Stents may be present in the dialysis access (arterial inflw, graft, r utflw vein). T assess stent patency, Measure velcities prximal, mid, and distal stent Diminished FV in the absence f utflw vein stensis If FV are lwer than 800 ml/min withut bvius utflw vein stensis Evaluate central venus utflw (subclavian and brachicephalic veins), t assess pssible central vein stensis r cclusin. Multiple venus branches near the shulder may indicate central vein stensis/cclusin Duplex the subclavian and axillary arteries t evaluate fr stensis Arterial inflw disease is rare, but mre likely in elderly, diabetics and thse with lng-standing renal disease Nte: AVF branches may als divert significant flw vlume and reduce flw alng the main cnduit. Steal Phenmenn Digit disclratin, cmplaints f numbness, r pain in the hand suggests a steal phenmenn may be present Dcument arterial flw beynd the arterial anastmsis Flw shuld be twards the hand, hwever all AV accesses steal. Gal f steal testing is t identify clinically significant steal. If it is retrgrade, cmpress the dialysis access (cntraindicated if fistula/graft had been accessed the same day) Nrmalizatin f flw with cmpressin cnfirms a steal phenmenn Clinically significant steal is uncmmn Cnsider btaining an rder fr digit brachial indices with and withut access cmpressin t cnfirm significance f steal phenmenn Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 8

9 Evaluatin f Dialysis 2014 REVIEW OF THE DIAGNOSTIC EXAM FINDINGS The technlgist/sngrapher/examiner shuld: Review data acquired during the Evaluatin f the Dialysis Access t ensure that a cmplete and cmprehensive evaluatin has been perfrmed and dcumented. Explain and dcument any exceptins t the rutine Evaluatin f the Dialysis Access examinatin prtcl (i.e., study limitatins, missins r revisins). Recrd all technical findings required t cmplete the final diagnsis s that the findings can be classified accrding t the labratry diagnstic criteria in the patient s medical recrd. Dcument the exam date, clinical indicatin(s), technlgist perfrming the exam and a summary f the exam results in the patient s medical recrd Alert health care prvider when immediate medical attentin is indicated based n exam findings and accrding t labratry prtcl. Dcument in patient s medical recrd. PRESENTATION OF EXAM FINDINGS Preliminary results may be prvided as established by internal guidelines in individual labratries. Present recrd f diagnstic images, data, explanatins, and technical wrksheet t the interpreting physician t use in rendering a diagnsis and fr archival purpses. EXAM TIME RECOMMENDATIONS High quality and accurate results are fundamental elements f the dialysis access examinatin. A cmbinatin f indirect and direct exam cmpnents is the fundatin fr maximizing exam quality and accuracy. Indirect exam cmpnents include pre-exam prcedures: btaining previus exam data; pre-exam paperwrk; exam rm and equipment preparatry activities; patient assessment and psitining; and, pst-exam prcedures: cleanup; cmpiling, prcessing, reviewing exam data fr preliminary and/r frmal interpretatin; patient cmmunicatin; exam charge and billing activities. Recmmended time alltment is 25 minutes. Direct exam cmpnents include equipment ptimizatin and the actual hands-n examinatin prcess. Recmmended exam time is minutes. If additinal testing is indicated fr steal phenmenn an additinal minutes will be required. Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 9

10 Evaluatin f Dialysis 2014 REFERENCES 1. NKF-K/DOQI clinical practice guidelines fr vascular access. AM J Kidney Des 48 [Supp 1]:S248-S273, Hubbard J, Markel K, Bendick P, Lng, G. Distal Revascularizatin-Interval Ligatin (DRIL) fr the treatment f dialysis access steal phenmenn. Jurnal f Diagnstic Medical Sngraphy, Nv 2009; Vl 25:pp Back MR, Maynard M, Winkle A, Bandyk D. Expected flw parameters within hemdialysis access and selectin fr remedial interventin f nnmaturing cnduits. Vasc Endvascular Surg Apr- May;42(2): Rbbin M, Chamberlain N, Lckhart ME, Gallichi M, Yung CJ, Deiehi MH, Alln M. Hemdialysis arterivenus fistula maturity: US evaluatin. Radilgy Oct;225(1): Cmeaux ME, Harkrider WW.: Clr Dppler imaging evaluatin f venus hypertensin in the upper extremity cmplicating vascular access graft. J Vascu Technl 1994; 18 (1): Eliades SJ, Eliades J.: Hemdynamic changes during dialysis in the arm and digits in the arms and digits f patients with plytetraflurethylene arterivenus grafts. J Vasc Technl. 1998, 22 (3): Singh P, Rbbin ML, Lckhart ME, Alln M. Radilgy. Clinically immature arterivenus hemdialysis fistulas: effect f US n salvage Jan;246(1): Cpyright by Sciety fr Vascular Ultrasund, All Rights Reserved. Printed in the United States f America. 1 0

Guidelines, Policies and Statements D19 Statement on Visceral Vascular Testing Using Ultrasound

Guidelines, Policies and Statements D19 Statement on Visceral Vascular Testing Using Ultrasound Guidelines, Plicies and Statements D19 Statement n Visceral Vascular Testing Using Ultrasund Disclaimer and Cpyright The ASUM Standards f Practice Bard have made every effrt t ensure that this Guideline/Plicy/Statement