Av fistula examination - copy

1. ‫للوصلة‬ ‫االكلينيكي‬ ‫الفحص‬
‫غسيل‬ ‫لمريض‬ ‫الوريدية‬ ‫الشريانية‬
‫الكلي‬
‫دكتور‬
‫العراقي‬ ‫طارق‬
‫الكلي‬ ‫أمراض‬ ‫استشاري‬

4. Two thin-walled Teflon cannulas with tapered ends were inserted near
the wrist in the forearm, one into the radial artery and the other into the
adjacent cephalic vein.
The external ends were connected by a curved teflon bypass tube.
Later, the Teflon tube was replaced by flexible silicon rubber tubing.

5. Clyde Shields, a Boeing machinist, survived for 11 years after the
insertion of his first AV shunt on 9 March 1960
 Two thin-walled Teflon cannulas with tapered ends
were inserted near the wrist in the forearm, one into
the radial artery and the other into the adjacent
cephalic vein.
The external ends were connected by a curved teflon
bypass tube. Later, the Teflon tube was replaced by
flexible silicon rubber tubing.

6. Scribner wrote in 1990: „Successful treatment
of Clyde Shields represents one of the few
instances in medicine where a single success
was required to validate a new therapy‟

8.  Physical examination of the
hemodialysis arteriovenous
fistula (AVF) is easy and
inexpensive and can often detect
common problems associated
with hemodialysis access with
high level of accuracy

9.  The 2006 National Kidney
Foundation Kidney Disease
Outcomes Quality Initiative (NKF-
K/DOQI) guidelines recommend
that physical examination
(monitoring) be performed on all
mature arteriovenous fistulas
(AVFs) on a weekly basis.
Clinical practice guidelines for vascular access.Vascular
Access,Work Group<Am J Kidney Dis. 2006;48 Suppl
1:S248.

10. Veins of the upper limb
 The brachial, radial, and ulnar veins are the major deep
veins that drain blood from the arm.
 The major superficial veins of the arm include
the cephalic
 and basilic veins,
 as well as the median cubital vein which joins the
two at the elbow.

12. Conventional types of Upper
Arm AVF

17.  Inspection — Examination of the patient with a hemodialysis
access includes inspection of the fistula itself as well as
inspection of the entire extremity.
 Fistula — The first step in a systematic evaluation of the mature
AVF is to examine
 the integrity of the skin overlying the fistula, which should
appear normal without erythema, focal masses, or focal
swelling.
 Cannulation sites should be well healed with minimal to no
scabbing and no evidence of inflammation.
 There should be no aneurysms (localized bulging zone) present.
If an aneurysm is present, the skin overlying the bulging area
should be examined for evidence of depigmentation, thinning,
ulceration, or spontaneous bleeding.

18.  ‫وكذلك‬ ‫نفسها‬ ‫الوصلة‬ ‫فحص‬ ‫للوصلة‬ ‫البصري‬ ‫الفحص‬ ‫يشمل‬
‫صورة‬ ‫في‬ ‫وذلك‬ ‫الوصلة‬ ‫به‬ ‫توجد‬ ‫الذي‬ ‫للطرف‬ ‫كامل‬ ‫فحص‬
‫الكتشاف‬ ‫للوصلة‬ ‫والمجاور‬ ‫المغطي‬ ‫للجلد‬ ‫فحص‬‫احمرار‬ ‫وجود‬
‫الدم‬ ‫أو‬ ‫لالرتشاح‬ ‫تجمع‬ ‫أو‬ ‫تنفخ‬ ‫أو‬
 ‫اذا‬ ‫ما‬ ‫وتحديد‬ ‫الغسيل‬ ‫ابر‬ ‫توصيل‬ ‫نقاط‬ ‫فحص‬ ‫كذلك‬ ‫ينبغي‬ ‫كما‬
‫بالتهاب‬ ‫مصابة‬ ‫كانت‬ ‫اذا‬ ‫ما‬ ‫واكتشاف‬ ‫لها‬ ‫كامل‬ ‫التئام‬ ‫حث‬ ‫قد‬ ‫كان‬
‫أماكن‬ ‫اختيار‬ ‫مع‬ ‫عدمه‬ ‫من‬ ‫الزالة‬ ‫تحتاج‬ ‫قشور‬ ‫وجود‬ ‫تحديد‬ ‫و‬
‫بسبب‬ ‫بالوصلة‬ ‫انتفاخات‬ ‫حدوث‬ ‫لتجنب‬ ‫وذلك‬ ‫االبر‬ ‫لوضع‬ ‫جديدة‬
‫واحدة‬ ‫منطقة‬ ‫وفي‬ ‫متقاربة‬ ‫نقاط‬ ‫في‬ ‫االبر‬ ‫وضع‬

19.  ‫االنتفاخات‬ ‫من‬ ‫خالية‬ ‫الوصلة‬ ‫تكون‬ ‫أن‬ ‫ينبغي‬
 aneurysms
 ‫وجود‬ ‫حال‬ ‫في‬aneurysms
 ‫ما‬ ‫واكتشاف‬ ‫لها‬ ‫المغطي‬ ‫الجلد‬ ‫فحص‬ ‫فينبغي‬ ‫ما‬ ‫وصلة‬ ‫في‬
‫ما‬ ‫وكذلك‬ ‫به‬ ‫المحيط‬ ‫الجلد‬ ‫عن‬ ‫للونه‬ ‫تغير‬ ‫حدث‬ ‫قد‬ ‫كان‬ ‫اذا‬
‫اذا‬
‫الدم‬ ‫بعض‬ ‫منه‬ ‫يخرج‬ ‫أو‬ ‫قروح‬ ‫به‬ ‫أو‬ ‫رقيقا‬ ‫كان‬

21.  Access inspection should also include
An evaluation of its diameter,
Usable length (portion available for cannulation),
and The presence of any obvious side branches.
In addition, there is a special maneuver that should be
performed— the arm elevation test.
Inspection should include the ipsilateral extremity,
shoulder, chest, breast, neck, and face.
It should also include a comparison with the opposite
extremity.

22.  ‫الوصلة‬ ‫قطر‬ ‫فحص‬
 ‫الغسيل‬ ‫ابر‬ ‫لتوصيل‬ ‫المتاح‬ ‫الوصلة‬ ‫طول‬ ‫تحديد‬
 ‫عدمه‬ ‫من‬ ‫جانبية‬ ‫اوردة‬ ‫وجود‬ ‫تحديد‬
‫ال‬ ‫فحص‬ ‫عمل‬ ‫الي‬ ‫باالضافة‬ the arm
elevation test.
 ‫شامال‬ ‫الوصلة‬ ‫به‬ ‫توجد‬ ‫الذي‬ ‫الطرف‬ ‫كامل‬ ‫يشمل‬ ‫أن‬ ‫ينبغي‬ ‫والفحص‬
‫والوجه‬ ‫والعنق‬ ‫الصدر‬ ‫منطقة‬ ‫و‬ ‫الكتف‬ ‫فيها‬ ‫بما‬ ‫الجهة‬ ‫كل‬
 ‫المقابلة‬ ‫بالجهة‬ ‫الوصلة‬ ‫بها‬ ‫التي‬ ‫الجهة‬ ‫مقارنة‬ ‫يتم‬ ‫وكذلك‬

24.  PE can also detect evidence of vascular steal syndrome
leading to hand ischemia .
 In the mildest cases, the affected hand is pale or cyanotic in
appearance compared with the opposite side.
 In more severe cases, evidence of ischemic changes in the
skin, especially at the fingertips, may be present.

25.  ‫أيضا‬ ‫يساعد‬ ‫الوريدية‬ ‫الشريانية‬ ‫للوصلة‬ ‫االكلينيكي‬ ‫الفحص‬
‫بها‬ ‫توجد‬ ‫التي‬ ‫لليد‬ ‫الشريانية‬ ‫التروية‬ ‫نقص‬ ‫اكتشاف‬ ‫في‬
‫الوصلة‬
 ‫الحاالت‬ ‫في‬ ‫وزرقان‬ ‫برودة‬ ‫وجود‬ ‫مالحظة‬ ‫يمكن‬ ‫حيث‬
‫الشريانية‬ ‫التروية‬ ‫نقص‬ ‫حاالت‬ ‫من‬ ‫والمتوسطة‬ ‫البسيطة‬
 ‫قد‬ ‫فانه‬ ‫الشريانية‬ ‫التروية‬ ‫نقص‬ ‫فيها‬ ‫تزيد‬ ‫التي‬ ‫الحاالت‬ ‫أما‬
‫األصابع‬ ‫أطراف‬ ‫في‬ ‫وخصوصا‬ ‫الجلد‬ ‫في‬ ‫تغيرات‬ ‫بها‬ ‫تظهر‬

26. Arm elevation
• When the extremity is elevated to a level above the
heart, there should be collapse of the fistula, at least
partially.
• If stenosis is present at some point in the fistula‟s
drainage circuit, then the portion of the fistula distal
(peripheral) to the lesion will stay distended while the
proximal (central) portion will collapse.

27. Arm elevation
 ‫الطرف‬ ‫رفع‬ ‫عند‬(‫الذراع‬)‫مستوي‬ ‫الي‬ ‫الوصلة‬ ‫يحمل‬ ‫الذي‬
‫وانهيار‬ ‫هبوط‬ ‫يحدث‬ ‫أن‬ ‫ينبغي‬ ‫فانه‬ ‫القلب‬ ‫مستوي‬ ‫من‬ ‫أعلي‬
(‫جزئي‬ ‫األقل‬ ‫علي‬ ‫أو‬ ‫كامل‬)‫للوصلة‬
‫وجود‬ ‫عي‬ ‫يدل‬ ‫فانه‬ ‫للوصلة‬ ‫الهبوط‬ ‫هذا‬ ‫حدوث‬ ‫عدم‬ ‫حالة‬ ‫في‬
‫الوصلة‬ ‫من‬ ‫المتدفق‬ ‫الدم‬ ‫طريق‬ ‫يعترض‬ ‫انسداد‬ ‫أو‬ ‫تضيق‬
‫الوصلة‬ ‫تتوسط‬ ‫نقطة‬ ‫في‬ ‫التضيق‬ ‫هذا‬ ‫كان‬ ‫واذا‬ ‫القلب‬ ‫الي‬ ‫عائدا‬
‫يحدث‬ ‫ال‬ ‫أنه‬ ‫حين‬ ‫في‬ ‫النقطة‬ ‫هذه‬ ‫بعد‬ ‫هبوط‬ ‫يحدث‬ ‫سوف‬ ‫فانه‬

28. Arm elevation test
.
(A)When the arm is dependent, the fistula is distended
(arrow).
(B) When the arm is elevated, the fistula is
collapsed (arrow).

29. Pulse
• A normal AVF should not be pulsatile.
• Or the pulse of the AVF is soft and easy compressible
• When a pulse is felt with increased intensity and
become forceful it is indicative of a downstream
obstruction.
• The severity of this obstruction is reflected in the
strength of the pulse.
• For this reason , a pulse in an access should be
considered an adverse finding.

30. Pulse
 ‫أو‬ ‫تنبض‬ ‫ال‬ ‫عادة‬ ‫السليمة‬ ‫الوريدية‬ ‫الشريانية‬ ‫الوصلة‬
‫عليه‬ ‫بالضغط‬ ‫يختفي‬ ‫ناعم‬ ‫خفيف‬ ‫نبض‬ ‫علي‬ ‫تحتوي‬
 ‫يعترض‬ ‫انسداد‬ ‫أو‬ ‫تضيق‬ ‫وجود‬ ‫يعني‬ ‫بالوصلة‬ ‫نبض‬ ‫وجود‬
‫علي‬ ‫الوريد‬ ‫ضغط‬ ‫في‬ ‫ارتفاع‬ ‫ويصاحبه‬ ‫للقلب‬ ‫الدم‬ ‫عودة‬
‫نسبة‬ ‫مع‬ ‫طرديا‬ ‫تناسبا‬ ‫النبض‬ ‫شدة‬ ‫وتتناسب‬ ‫الغسيل‬ ‫ماكينة‬
‫التضيق‬
 ‫سلبيا‬ ‫شيئا‬ ‫الوصلة‬ ‫في‬ ‫نبض‬ ‫وجود‬ ‫يعتبر‬ ‫لذا‬

31. Thrill
 A thrill is a palpable vibration
 A thrill, or bruit, at the anastomosis is indicative of
flow.
 Thrill is diffuse , soft and continuous (systolic and
diastolic).
• When feeling for the thrill (or listening to a bruit), it is
important to focus on both the diastolic and systolic
components.
• Normally, a very prominent continuous thrill is present
at the anastomosis.

32. THRILL
 thrill ‫المحسوس‬ ‫االهتزاز‬(‫الزنة‬)‫ال‬ ‫عليه‬ ‫يطلق‬ ‫ما‬ ‫هو‬
 ‫اثناء‬ ‫متواصل‬ ‫و‬ ‫محسوس‬ ‫ناعم‬ ‫اهتزاز‬ ‫عن‬ ‫عبارة‬ ‫وهو‬
‫وانبساطه‬ ‫القلب‬ ‫انقباض‬
 ‫موضع‬ ‫عند‬ ‫هو‬ ‫بالزنة‬ ‫االحساس‬ ‫فيه‬ ‫يمكن‬ ‫مكان‬ ‫وأكثر‬
‫نحو‬ ‫اتجهنا‬ ‫كلما‬ ‫تدريجيا‬ ‫حدته‬ ‫تقل‬ ‫ثم‬ ‫بالوريد‬ ‫الشريان‬ ‫اتصال‬
‫يختفي‬ ‫أن‬ ‫الي‬ ‫القلب‬
 ‫انقباض‬ ‫أثناء‬ ‫يكون‬ ‫عادة‬ ‫والذي‬ ‫اختفائه‬ ‫بعد‬ ‫ال‬ ‫ظهور‬ ‫معاودة‬
‫هذه‬ ‫قبل‬ ‫الوصلة‬ ‫في‬ ‫ضيق‬ ‫وجود‬ ‫علي‬ ‫دليل‬ ‫هو‬ ‫القلب‬ ‫عضلة‬
‫مباشرة‬ ‫النقطة‬thrill

33. • A thrill at any point other than the anastomosis is
indicative of turbulence in the flow, indicating a
stenotic lesion at that point.
• With stenosis, the diastolic portion of the thrill
becomes shortened
• and will eventually disappear, leaving only the
systolic component

35. Pulse augmentation
• If the body of the fistula is manually occluded several
centimeters from the anastomosis, the pulse in the fistula
distal to that point should become hyperpulsatile.
• This maneuver is referred to as “checking the pulse
augmentation.”
• The degree of pulse augmentation is directly proportional to
the arterial inflow pressure.
• Although this is a subjective assessment, very useful
information can often be obtained from this evaluation,
especially by an experienced examiner

36. Pulse augmentation
 ‫وعلي‬ ‫بفحصها‬ ‫يقوم‬ ‫من‬ ‫بواسطة‬ ‫للوصلة‬ ‫كامل‬ ‫انغالق‬ ‫احداث‬ ‫عند‬
‫ينبغي‬ ‫فانه‬ ‫بالوريد‬ ‫الشريان‬ ‫توصيل‬ ‫نقطة‬ ‫من‬ ‫قليلة‬ ‫سنتيمترات‬ ‫بعد‬
‫النبض‬ ‫في‬ ‫الزيادة‬ ‫تتناسب‬ ‫و‬ ‫بالوصلة‬ ‫المحسوس‬ ‫النبض‬ ‫يزداد‬ ‫أن‬
‫للوصلة‬ ‫المغذي‬ ‫بالشريان‬ ‫الدم‬ ‫ضغط‬ ‫قوة‬ ‫مع‬ ‫طرديا‬ ‫تناسبا‬
 ‫من‬ ‫المنطقة‬ ‫بهذه‬ ‫تضيق‬ ‫وجود‬ ‫الي‬ ‫تشير‬ ‫الزيادة‬ ‫هذه‬ ‫حدوث‬ ‫وعدم‬
‫الغسيل‬ ‫اجراء‬ ‫في‬ ‫وصعوبة‬ ‫الوصلة‬ ‫في‬ ‫ضعف‬ ‫عليها‬ ‫ويترتب‬ ‫الوصلة‬
‫الدم‬ ‫لسحب‬ ‫الالزم‬ ‫السلبي‬ ‫الضغط‬ ‫في‬ ‫زيادة‬ ‫صورة‬ ‫في‬ ‫يظهر‬ ‫منها‬
‫الغسيل‬ ‫جهاز‬ ‫الي‬ ‫الوصلة‬ ‫من‬

37. Thank you