1. Doppler US of A-V access for hemodialysis
Samir Haffar M.D.
Department of Internal Medicine
Al-Mouassat University Hospital – Damascus – Syria

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. 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. Anatomy of aortic arch & subclavian artery
Right SCA originates from innominate (brachiocephalic) artery
Left SCA originates directly from aortic arch
SCA has several branches: VA & mammary (internal thoracic) artery
Thrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, 2nd edition, 2005.

5. Arterial anatomy of upper
extremity
Thrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, 2nd edition, 2005.
LSA Common origin with CCA from A
BA High bifurcation of brachial artery
RA High origin from axillary artery
UA High origin from axillary artery
Anatomical variations

6. Normal brachial artery
Deklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.
Diameter from intima to intima
Perpendicular to arterial wall
Sagittal US scan Sagittal color Doppler
Homogenous velocities
Good visualisation of arterial bords

7. Normal duplex US of peripheral arteries
High resistance flow
Normal brachial arteryTriphasic flow

8. Venous anatomy of upper extremity
Deklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.
Superficial system
Basilic vein Drains medial side of upper limb
Penetrates fascia in lower arm to join brachial vein
Cephalic vein Drains lateral side of upper limb
Join axillary vein in infraclavicular region

9. Normal venous flow
 Spontaneity Spontaneous flow without augmentation
 Phasicity Flow changes with respiration
 Compression Transverse plane
 Augmentation Compression distal to site of examination
Patency below site of examination
 Valsalva Deep breath, strain while holding breath
Patency above site of examination

10. Vein compressibility
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
Compression
Regular thin wall
Diameter: 5.2 mm
Basilic vein
Vein fully compressed
Basilic vein

11. Color & pulsed Doppler of cephalic vein
Mihmanli I et al. J Ultrasound Med 2001 ; 20 : 217 – 222.
Normal lumen blush
Normal respiratory phasicity

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. Doppler US criteria for good outcome
Evaluation of nondominant arm first
• Peripheral arteries Diameter at least 1.6 mm
Hyperemic response
Patent palmar arch (US Allen test)
• Peripheral veins AVF: ≥ 2 mm without tourniquet
≥ 2.5 mm with tourniquet
Graft: at least 4 mm with tourniquet
• Central veins Respiratory phasicity
“indirect assessment” Transmitted cardiac pulsatility
Valsalva (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. Measurement of artery diameter
Ferring M et al. Nephrol Dial Transplant 2008 ; 23 : 1809 – 1815.
Radial artery (M mode)
Point of artery insonated over time
Diameter at peak systole: 2.1 mm
Diameter in diastole: 2 mm
From intima to intima
Perpendicular to arterial wall
Diameter: 2.2 mm
Radial artery (B mode)
Blooming effect

15. Arterial hyperemic response
Useful to predict risk of arterial steal
Wiese 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 < 0.70
Failure of such response regarded as CI to AVF

16. Pourcelot’s resistance index
Resistance Index (RI): Systolic – End Diastolic / Systolic

17. Color Doppler of the palmar arch
Reversed flow
Flow via ulnar artery
Occlusion of radial artery
while imaging arch
Color Doppler
of palmar artery
Mozersky 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 test
First reported in 1973

18. Radial artery at wrist
Segmental occlusive lesions
Calcified wall with marked shadowing
Parmley MC et al. Am J Surg 2002 ; 184 : 568 – 572.

19. Spontaneity
Phasicity
Compressibility
Lumen echogenicity
Wall irregularity
Diameter
Veins examined from wrist to distal end of clavicle
Mihmanli I et al. J Ultrasound Med 2001 ; 20 : 217 – 222.

20. Cephalic vein wall
Marked wall irregularity
Wall thickening especially on posterior side
Mihmanli I et al. J Ultrasound Med 2001 ; 20 : 217 – 222.

21. Robbin ML et al. Radiology 2000 ; 217 : 83 – 88.
Normal caliber of SCV
50% stenosis of BCV
Corresponding venogram
Abnormal respiratory phasicity
No decrease to baseline with inspiration
Doppler US of patent SCV
Central vein stenosis
Paget Schroetter syndrome

22. Central vein stenosis
Paget Schroetter syndrome
Robbin ML et al. Radiology 2000 ; 217 : 83 – 88.
Doppler US of patent SCV
Abnormal respiratory phasicity
Monophasic flow
Suspicion of CV stenosis/occlusion
Corresponding venogram
Severe stenosis of BCV
at its junction with SMV
Second channel adjacent to stenosis
Recognition of central vein stenosis is CI to use of that extremity

23. Upper extremity arterial mapping
Brown PWG. Eur J Vasc Endovasc Surg 2006 ; 31 : 64 – 69.

24. Upper extremity vein mapping
Cephalic vein
Mendes RR et al. J Vasc Surg 2002 ; 36 : 460 – 3.
Eight representative measurement sites of CV:
Diameter with & without tourniquet
Depth from skin

25. Preoperative vascular mapping
Robbin ML et al. Radiology 2000 ; 217 : 83 – 88.
50-year-old man with nonpalpable cephalic vein in wrist
Scheduled to receive forearm graft
Transverse cephalic veinRadial artery
at wrist
3.7 mm
Wrist
2.8 mm
Middle forearm
2.7 mm
Antecubital area
2.8 mm
Adequate diameters for AVF placement

26. Preoperative vascular mapping
Duplex sonography of upper limb arteries & veins
performed in conjunction with clinical examination in all
patients for whom an AVF is being considered
* National Kidney Foundation’s
Kidney Disease Outcomes Quality Initiative
National Kidney Foundation. Am J Kidney Dis 2006 ; 48(Suppl. 1) : S1 – S322.
Recommendations of NKF-KDOQI*

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. Brescia-Cimino A-V fistula
Brescia MJ, Cimino JE, Appel K, et al. N Engl J Med 1966 ; 275 : 1089 – 92.
Side of artery to end of vein
At anatomical snuffbox or wrist
Surgeons who invented AVF:
Brescia, Cimino, & Appel
Most commonly used

29. Types of Arterio-Venous Fistula
Finlay DE et al. RadioGraphics 1993 ; 13 : 983 – 999.
Side of artery to side of vein
End of artery to side of vein
Side of artery to end of vein
Brescia-Cimino AVF
End of artery to end of vein

30. Types of A-V grafts (PTFE – Polyurethane )
Curr Probl Surg 2011 ; 48 : 443 – 517.
Forearm
Barachial artery to brachial vein
“Loop graft”
Upper arm
Radial artery to axillary vein
“Straight graft”

31. A-V access for hemodialysis in preferential order
Type Description
 Forearm AVF Radial artery to cephalic vein
Radial artery to basilic vein
Radial artery to other suitable vein (transposition*)
AVF placement preferable to graft placement
Nondominant arm is preferred site for access placement
* Transposition AVFs placed in veins other than cephalic vein
Robbin ML et al. Radiology 2000 ; 217 : 83 – 88.
 Upper arm AVF Brachial artery to cephalic vein
Brachial artery to basilic vein
Brachial 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. Distribution of AVF & graft use in Europe
& the United States
Huijbregts HJ et al. Eur J Vasc Endovasc Surg 2006 ; 31 : 284 – 287.
Following percentiles of each distribution provided for
the 10th, 25th, 50th (median), 75th, & 90th percentiles

33. Radio-cephalic fistula at wrist
MA (8 prospective & 30 retrospective studies – 4579pts)
High primary failure rate
Moderate 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 weeks
15.3% (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-establish
patency, thrombosis or time of patency measurement
62.5% (95% CI: 54.0 – 70.3%)

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. Doppler US of A-V access for hemodialysis
Abundant gel & minimal pressure on skin
Longitudinal & transverse scan from feeding artery to anastomosis
Longitudinal & transverse scan from draining vein as far as possible
Perivascular space: functional stenosis from abscess, hematoma, seroma
Edenberg Jan et al. Tidsskr Nor Legeforen nr. 2009 ; 129 : 1635 – 8.

36. Normal Doppler US in AVFs
• Feeding artery Monophasic flow
Large diastolic component
• Anastomosis Perivascular tissue vibration
Very turbulent flow over long stretch
• Draining vein Pulsatile flow (arterialized vein)
• Volume flow > 500 mL/min
Dilatation of feeding artery & draining vein
after several years of use
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

37. Normal Doppler US in AVFs
Brachio-basilic fistula
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
Brachial artery
Monophasic flow
Large diastolic component
Brachio-basilic fistula
Arterialized vein

38. Doppler US of polyurethane graft
Three-layered material – Cannulation within 24 h
Wiese P et al. Nephrol Dial Transplant 2003 ; 18 : 1397 – 1400.
1 year follow-up
Signal from whole graft
Early post-operative
Strong reflection from graft
1 year follow-up
Signal at site of single cannulation
1 year follow-up
Signal at sites of repeat cannulation

39. Volume = Cross-sectional area . Mean velocity . 60
(mL/min) (cm2) (cm/sec)
Cross-sectional area (cm2): π d2 / 4
d: diameter
Measurement of flow volume
Hoskins P et al. Diagnostic US: physics and equipment.
Cambridge university press, Cambridge, UK. 2nd ed, 2010.

40. Place of flow volume measurement
• Arteriovenous fistula
Feeding artery Brachial artery in middle upper arm
Recommended by some authors
Within fistula Turbulent flow (spectral broadening)
Draining vein Abrupt change in diameter in older AFV
Changes in lumen shape (elliptical)
Recommended by other authors
• Graft
Investigated along the entire access
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

41. Measurement of flow volume /Feeding artery
Diameter perpendicular to axis
Sample volume across width of vessel
Sample volume in same site of diameter measurement
Correct estimation of angle
TAMV: 3 – 5 cardiac cycles
Deklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.

42. Measurement of flow volume in feeding artery
Deklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.
Normal flow in distal radial artery
Flow volume (fistula open) – Flow volume (fistula closed)
Normal volume in upper limb: 100 mL/min (neglected)
Reversed flow in distal radial artery
Flow volume (proximal a) + Flow volume (distal a)

43. Sources of error in volume measurement
• Diameter Measuring accuracy (blooming effect)
Main source Assumption of circular cross-section
Variation during cardiac cycle
Variation during respiration (veins)
• Doppler angle As small as possible & < 60
Box steering & transducer shifting
• Mean velocity Setting of transmitted & received gain
Over or underestimation
Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2nd edition, 2011.

44. Error percentage in volume measurements
& vessel diameter
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Errors ranging from 0.2 to 1.0 mm

45. Doppler phenomenon?
Doppler shift frequency (fd): ft – fr
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
ft
fr
∆ F = 2 F0 V Cos Ө / C

46. Angle of insonation & Doppler effect
Kim Min Ju et al. Curr Probl Diagn Radiol 2009 ; 38 : 53 – 60.
Angles between 30 to 60 usually used for Doppler acquisition

47. Error percentage in velocity measurements
& angle of insonation
Angle of insonation > 60 should not be used

48. Doppler angle correction in AVF
Pieturaa R et al. Eur J Radiol 2005 ; 55 : 113 – 119.

49. Adjusting spectral Doppler gain
Gain setting too low
Correct gain setting
Gain setting too high
Kruskal JB et al.RadioGraphics 2004 ; 24 : 657 – 675.

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. Interpretation of fistula flow volume
A-V access for hemodialysis Flow volume (mL/min)
Normal value
Forearm fistula
Upper arm fistula
600 – 800
900 – 1200
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Mature fistula ≥ 500
High risk of occlusion
AVF
Graft
< 300
< 650
High-output cardiac failure
Adult
Children
> 3.000
> 700

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. Causes of immature fistula
 Stenosis at or near the fistula
Angioplasty – surgical revision
 One or more accessory veins
Ligation
 Deep draining vein
Fistula surgically placed in more superficial soft tissues
Immature fistula can be converted into usable fistula
with correction of underlying problem
Singh P et al. Radiology 2008 ; 246 : 299 – 305.

54. Sonographically mature fistula
Doppler 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/min
Robbin ML. Radiology 2002 ; 225 : 59 – 64.
Singh P et al. Radiology 2008 ; 246 : 299 – 305.
Should meet the 3 following criteria
Criteria different from clinically mature fistula

55. Doppler US for routine surveillance
• AP diameter of draining vein in transverse scan
Usually thin wall: cursors within vein walls
• Distance from skin to anterior wall of draining vein
• Veins branching off within first 10 cm of anastomosis
AP diameter & distance from anastomosis
• Flow volume Straight segment of artery or vein
Repeat 3 – 5 times with average
Singh P et al. Radiology 2008 ; 246 : 299 – 305.

56. Mature fistula/Good diameter & depth
Anteroposterior diameter of draining vein: 6 mm
Distance from skin surface to anterior vein wall: 4.8 mm
Singh P et al. Radiology 2008 ; 246 : 299 – 305.
Transverse US of draining vein

57. Mature fistula/Good flow volume
Brachio-basilic fistula
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
Diameter: 7.9 mm
TAMV: 93.2 cm/sec over 3 cardiac cycles
Flow volume: 2.741 mL/min

58. Immature fistula/Large accessory vein
Singh P et al. Radiology 2008 ; 246 : 299 – 305.
Large accessory vein which may limit maturation of fistula
Search for all accessory veins within first 10 cm of anastomosis
Transverse US of draining vein

59. Immature fistula/Small & deep vein
Draining vein
Vein too small (3.1 mm)
Vein too deep (7.6 mm)
Singh P et al. Radiology 2008 ; 246 : 299 – 305.

60. Immature fistula/Low flow volume
Radio-cephalic fistula
Left radial artery
Flow volume : 86 mL/min
Left cephalic vein
Flow volume : 130 mL/min
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.

61. Routine surveillance in asymptomatic patients
No RCTs of Doppler surveillance in this setting
Routine surveillance by combination of clinical examination,
direct flow measurement, & duplex US should be performed
When stenosis > 50% is accompanied by hemodynamic
or clinical abnormalities, angioplasty is recommended
* National Kidney Foundation’s
Kidney Disease Outcomes Quality Initiative
National Kidney Foundation. Am J Kidney Dis 2006 ; 48(Suppl. 1) : S1 – S322.
Recommendations of NKF-KDOQI*

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. Complications of A-V access for hemodialysis
 Stenosis & occlusion
 Aneurysm & pseudoaneurysm
 Arterial steal syndrome
 High-output cardiac failure
Hematoma
Seroma
Lymphocele
 Infected & non-infected collections

64. Mechanisms & sites of stenosis
• AVF Feeding artery Atherosclerosis (SC, axillary)
• Graft Intimal hyperlplasia (shear stress)
Anastomosis between graft & vein
Draining vein Intimal hyperplasia (valves)
Puncture-induced dissection
Proximal – distal
Anastomosis Turbulence (most common)
Central veins Catheters (SC, axillary)
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

65. Venous stenosis from intimal hyperplasia
Edenberg Jan et al. Tidsskr Nor Legeforen nr. 2009 ; 129 : 1635 – 8.
Venous stenosis 3 cm from anastomosis
Power Doppler ultrasound

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 ratio
PSV: should not be interpreted in isolation

67. Measurement of luminal diameter reduction
Edenberg 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 mm
78 % diameter stenosis
Original lumen – Residual lumen
x 100% of diameter stenosis
Original lumen
=

68. Color criteria of significant stenosis
Pronounced aliasing at site of stenosis
Junction of basilic & axillary vein

69. Duplex criteria for significant stenosis (> 50%)
• Direct signs
Feeding artery PSV ratio ≥ 2
Anastomosis PSV ratio ≥ 3 – PSV > 400 cm/sec*
Draining vein PSV ratio ≥ 3 – PSV > 300 cm/sec*
• Indirect signs
Flow volume < 250 mL/min
Proximal High-resistance flow (RI > 0.70)
Distal Delayed systolic upstroke
* Flow volume adequate for hemodialysis
Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2nd edition, 2011.

70. PSV ratio
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
Proximal: 2 cm proximal to stenosis
Stenosis: same Doppler angle if possible

71. Significant stenosis of AVF at anastomosis
Radio-cephalic fistula
PSV ratio: 3.4
Arterio-venous anastomosis
PSV: 438 cm/s
Radial artery
PSV: 130 cm/s
Grogan J et al. J Vasc Surg 2005 ; 41 : 1000 – 6.

72. Proximal venous stenosis
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
Pronounced aliasing at site of stenosis
Peak Systolic Velocity: 610 cm/s
Cephalic vein – Mid upper arm

73. Distal venous stenosis
Deklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.
Pronounced aliasing at site of stenosis
Peak Systolic Velocity: 340 cm/s
Junction of basilic & axillary vein

74. Stenosis of graft insertion on vein
Deklunder G et al. EMC-Radiologie 2004 ; 1 : 632 – 646.
Rail aspect of the graft
Aliasing on color Doppler
Peak Systolic Velocity : 400 cm / s

75. Pseudo-diagnosis of significant stenosis
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
PSV: 570 cm/sec
Brachio-basilic fistulaBrachial artery
PSV: 350 cm/sec
Volume flow:1.1 L/min
High inflow
Basilic vein
PSV: 175 cm/sec
Volume flow:1.8 L/min
High outflow
High PSV in anastomosis due to high flow volume & large vessels

76. Occlusion of brachiocephalic fistula
Triphasic waveform
RI = 1 (thrombosed fistula)
Brachial artery
Occlusion of fistula
Thrombus within draining vein
Brachio-cephalic fistula
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.

77. Thrombosis in draining vein of AVF
Edenberg 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. Complications of A-V access for hemodialysis
 Stenosis & occlusion
 Aneurysm & pseudoaneurysm
 Arterial steal syndrome
 High-output cardiac failure
Hematoma
Seroma
Lymphocele
 Infected & non-infected collections

79. Aneurysm
Develops in AVF functioning for many years
• Good function Lumen not filled with thrombus
Intact skin
• Intervention Intra-luminal thrombus
rarely needed Compromise of overlying skin
Steadily & rapidly enlarged
Obstructive kinks
• Operation Proximal A-V access of arterialized vein
Prosthetic graft
Padberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.

80. Diffuse aneurysmal dilation
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Secondary to wall degeneration or downstream stenosis
Feeding artery
Draining vein
Anastomosis

81. True venous aneurysm
Diffuse aneurysmal dilation
Bourquelot P et al. Nephrol Ther 2009 ; 5 : 239 – 248.
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
Raise concern from the staff
Radio-cephalic AVF Color Doppler US

82. Pseudoaneurysm
• Incidence 2 – 10 % during functional life of graft
Less 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 & stable
Treatment if expanding
Anastomotic Generally requires surgery
Infection is common cause
Padberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.

83. Anastomotic pseudoaneurysm on A-V graft
Kabalci YM et al. Transplant Proc 2006 ; 38 : 2816 – 2818.
Brachio-basilic graft 2 months ago
Anastomotic pseudoaneurysm of graft is rare

84. Pseudoaneurysm
Color Doppler
“yin -yang pattern”
Pulsed Doppler
“to-and-fro waveform”
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

85. Perivascular space with pulsatile flow
Bidirectional blood flow
Typical “yin-yang sign”
Pseudoaneurysm of radial artery
Color duplex US Thrombin injection under US control
Complete thrombosis after
thrombin injection
Carrafiello G et al. Injury Extra 2006 ; 37 : 78 – 81.

86. Complications of A-V access for hemodialysis
 Stenosis & occlusion
 Aneurysm & pseudoaneurysm
 Arterial steal syndrome
 High-output cardiac failure
Hematoma
Seroma
Lymphocele
 Infected & non-infected collections

87. Hematoma
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.
AV access punctured thrice weekly for hemodialysis
Serial examinations to monitor evolution of hematoma

88. Complications of A-V access for hemodialysis
 Stenosis & occlusion
 Aneurysm & pseudoaneurysm
 Arterial steal syndrome
 High-output cardiac failure
Hematoma
Seroma
Lymphocele
 Infected & non-infected collections

89. Radial artery steal
Finlay DE et al. RadioGraphics 1993 ; 13 : 983 – 999.
Ulnar artery flow contributes to fistula flow via palmar arches
Retrograde flow in distal radial artery

90. Arterial steal syndrome
Clinical diagnosis – Incidence (1 – 4 %)
• Risk factor Brachial arterial, DM, female gender
• Symptoms Steal phenomenon Silent (70% of RC-AVF)
Steal syndrome Mild: pain during dialysis
Severe: rest pain, ulceration
Common cause of neuropathy
• Doppler US Reversed flow: complete – only in diastole
Dynamic study: gentle compression of AVF
• Treatment Ligation, banding, rerouting
Padberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.

91. Radial arterial steal
Frequent in asymptomatic patients
Wiese 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. Reversed flow in distal RA after AVF
Goldfeld M et al. AJR 2000 ; 175 : 513 – 516.
Reversed flow during entire cardiac phase

93. Arterial steal syndrome
Radial-cephalic fistula
Yilmaz C et al. AJR 2009 ; 193 : W567.
RA distal to anastomosis
Antegrade flow during systole
Retrograde flow during diastole
Gentle compression of fistula
Restoration of antegrade flow
Elevated systolic flow
Elevated diastolic flowBidirectional flow

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 US
Padberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.

95. Digital ischemia from emboli of thrombosed AVF
7 reported cases in the literature
Journet J et al. Néphrologie & Thérapeutique 2010 ; 6 : 121 – 124.
Digital ischemia
4 fingers of right hand
Regression of ishemia
6 mth after operation
Partial thrombosis
of RC-AVF

96. Complications of A-V access for hemodialysis
 Stenosis & occlusion
 Aneurysm & pseudoaneurysm
 Arterial steal syndrome
 High-output cardiac failure
Hematoma
Seroma
Lymphocele
 Infected & non-infected collections

97. High-output cardiac failure
Rare &unusual complication
• Symptom Symptoms of right heart failure
Nicoladoni-Branham sign: ↓ PR after AVF occlusion
• Diagnosis Flow volume > 3 L/min
Flow volume/cardiac output ≥ 30% (screening)
Cardiac output > 2.3 L/min/m2
Sine qua none: improvement after treatment
• Treatment Ligation: sacrifice of access
Banding: more attractive option
Padberg FT et al. J Vasc Surg 2008 ; 48 : 55S – 80S.

98. Conclusion
• Doppler uplex US should be interpreted in conjunction with
clinical findings including adequacy of dialysis
• Results should be discussed within multidisciplinary team:
Nephrologist, vascular surgeon, & interventional radiologist
• Stenosis in early postop period interpreted with caution
They may be secondary to transient edema
• Duplex sonography is central to prevention, detection, and
management of complications
Kerr SF et al. Clin Radiol 2010 ; 65 : 744 – 749.

99. References
1. Kerr SF et al. Duplex sonography in the planning & evaluation of
arteriovenous fistula for hemodialysis Clin Radiol 2010;65:744-749.
2. Wiese P et al. Color Doppler ultrasound in dialysis access. Nephrol
Dial Transplant 2004;19:1956-1963.
3. Padberg FT et al. Complications of arteriovenous hemodialysis
access: 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. Thank You