HD Scanning: Velocities and Volume Flow
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1 HD Scanning: Velocities and Volume Flow Non-Invasive Lab Symposium West Orange, NJ April 27, 2018 Volume Flow Cindy Sturt, MD, FACS, RVT
2 500,000 Americans on dialysis 20-25% annual mortality 65% 5 year mortality National Kidney Foundation
3 Life line of dialysis patients
4 Arterial venous fistula Upper arm Brachial artery Lower arm Radial artery
5 Straight Looped Arterial Venous Grafts Life line
6 Achille s Heel Stenosis Thrombosis
7 Intervention (to prevent thrombosis) Balloon angioplasty
8 Intervention (to prevent thrombosis) Stenting
9 AV access Lifeline Achilles heel Stenosis Angioplasty
10 Clinical Monitoring Surveillance Bleeding, difficult cannulations, arm swelling, chest wall collateralization, increased pulsatility, decreased thrill Surveillance Access flow Recirculation Venous pressure Ultrasound Dialysis Unit
11 Access flow decrease <600cc/min or < 1000cc/min with >25% decrease over 4 month prior Increased venous pressure during dialysis >150mmHg or trend of persistent increasing pressure over time
12 Semin Dial March; 28(2):E23-E29. Our results add to the uncertainty of access blood flow monitoring as a surveillance method of hemodialysis accesses.
13 anastomosis AVF Ultrasound B mode Inflow artery Color Doppler Spectral Doppler
14 Ultrasound - Carotid Circulation Normal Doppler Spectra ICA ECA CCA Zwiebel WL et al Thrush A. Harshorne et al. 2005
15 Ultrasound Mesenteric circulation SMA: PSV > 275cm/s 70% stenosis Celiac: PSV > 250cm/s 70% stenosis
16 Ultrasound peripheral circulation 2011 ACC/AHA guidelines for management of PVD ultrasound is useful in diagnosing location and severity of stenoses.
17 Ultrasound Dialysis Circuit Tortuosity Aneurysms/pseudoaneurysm Angulation of anastomosis Compliance of vein/grafts different from arteries Diameter of vein varies along its length
18 Grayscale/color doppler inflow anastomosis outflow +/- subclavian vein Spectral waveforms and velocity Inflow Anastomosis proximal outflow (beyond anastomosis subclavian vein Blood flow volume from at least one site. Abnormalities require additional images, waveforms, velocity measurements.
19 Velocity Christian Johann Doppler
20 Normal brachial artery: Triphasic High resistance Inflow artery Brachial artery after access creation Monophasic flow Large diastolic component Low resistance venous outflow (AV access)
21 Normal Velocity cm/s
22 Stenosis in AVF PSV > cm/s suggest > 50% stenosis
23 Stenosis at anastomosis angulation angulation PSV > 600 cm/s suggest stenosis?
24 Occlusion of AVF Triphasic brachial artery waveform in association with an occluded brachiocephalic fistula Occlusion of brachiocephalic fistula. Thrombus within the vein
25 Volume Flow Volume (cc/min)= Area (cm2) x Velocity (cm/s) Diameter (longitudinal) velocity
26 Volume flow Straight segment 5cm away from anastomosis/stenoses/major abnormalities Some recommend measuring at brachial artery
27 Volume Flow Volume (cc/min)= Area (cm2) x Velocity (cm/s) x 60 Diameter (longitudinal) Longitudinal view Systole Measure in non-aneurysmal area
28 Volume Flow Volume (cc/min)= Area (cm2) x Velocity (cm/s) x 60 Sample volume needs to include the whole diameter of the vessel and not just the middle Parabolic flow rbcs in the middle of the vessel travel faster rbcs in at the periphery of the vessel travels slower
29 Volume Flow Volume (cc/min)= Area (cm2) x Velocity (cm/s) x 60 velocity Mean velocity throughout the blood vessel average over a few cycles.
30 Volume Flow
31 Conclusion Ultrasound can be very important in the surveillance of dialysis access. When used accurately, can identify stenoses. Need to better understand and come up with appropriate criteria to indicate stenosis. Probably cannot be used in isolation and clinical monitoring is important.
32 Thank You
33
34 Peak systolic velocities Normal duplex of peripheral arteries. High resistance waveforms. High resistance flow leading to triphasic waveforms.
35 Volume Flow Triphasic brachial artery waveform in association with an occluded brachiocephalic fistula Occlusion of brachiocephalic fistula. Thrombus within the vein
36 Ultrasound Renal Circulation Renal guidelines as listed.
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