Physical examination is an important tool for evaluating arteriovenous fistulas (AVFs) used for hemodialysis access. The summary examines key aspects of physically examining an AVF: 1) Inspection of the AVF and arm includes examining the skin, cannulation sites, and checking for aneurysms. The size, length, and branches are also evaluated. 2) Techniques like arm elevation, pulse examination, thrill assessment, and pulse augmentation help detect stenosis or other problems like vascular steal syndrome. 3) Accessory veins can be identified by looking for multiple veins or palpating branches, and evaluating flow changes when compressing sections of the access.

1. AV Fistula Examination
TAREK ELERAKY
Consultant Nephrologist
Egyptian Board of Nephrology
ISN Fellowship (Hammersmith Hospital ,London,UK)
Interventional Nephrology Fellowship ( Sant Mary’s Hospital,Catholic
university,, Seoul ,South Korea)

4. In 2002, Scribner received the Albert Lasker
Award for Clinical Medical Research, together with
Willem J. Kolff.
 WILLEM KOLFF IS FAMOUSLY THE MAN WHO FIRST PUT THE
DEVELOPING THEORY OF THERAPEUTIC DIALYSIS INTO SUCCESSFUL
PRACTICE IN THE MOST UNLIKELY CIRCUMSTANCES: KAMPEN, IN THE
OCCUPIED NETHERLANDS DURING WORLD WAR II.
 INFLUENCED BY A PATIENT HE HAD SEEN DIE IN 1938, AND IN A
REMOTE HOSPITAL TO AVOID NAZI SYMPATHISERS PUT IN CHARGE IN
GRONINGEN, HE UNDERTOOK EXPERIMENTS WITH CELLULOSE TUBING
AND CHEMICALS AND THEN WENT STRAIGHT ON TO MAKE A MACHINE
TO TREAT PATIENTS FROM 1943.
 HIS FIRST 15 PATIENTS DIED, BUT THE 16TH, A 67-YEAR-OLD WOMAN
WITH ACUTE RENAL FAILURE CAUSED BY SEPTICAEMIA, RECOVERED
AFTER 11 HOURS OF DIALYSIS

5. Willem J. Kolff rotating-drum kidney
was a fearsome beast. Blood ran around cellulose (sausage skin) tubing,
wound round a drum made of wooden slats, dipping into the ‘bath’ of
dialysate at the bottom of its turn. The movement of blood was powered
by the rotation of the drum rather than a blood pump. The surface area of
the dialyzer was respectable by modern standards at over 2 m2, but it
required up to two units of blood to prime the tubing before each dialysis,
and ultrafiltration control was inaccurate and unreliable – achieved by
adding variable amounts of glucose to the ‘bath’. Dialysate was made by
stirring weighed salts into the tap water bath. A water pump from a
model T Ford powered rotation.

6. In 1960, he, Wayne Quinton, and David Dillard invented a
breakthrough device, the Scribner shunt.
The device subsequently saved the lives of numerous people
with end-stage kidney disease around the globe. The first
patient treated was Clyde Shields; due to treatment with the
new shunt technique, he survived his chronic renal failure for
more than eleven years, dying in 1971.
Belding Hibbard Scribner (January
18, 1921 – June 19, 2003)

7. 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.

8. 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.

9. 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’

10. The legendary paper ‘Chronic hemodialysis using
venipuncture and a surgically created arteriovenous
fistula’ was published by Brescia, Cimino, Appell and
Hurwich .
Dr Appell was the surgeon in the team. The first
surgically created fistula for the purpose of
haemodialysis was placed on 19 February 1965,
followed by further 14 operations as of 21 June 1966.
Twelve out of these 14 AV fistulae resumed primary
function without complications,
Two never functioned (in the first patient, the
anastomosis ‘was made too small’). This represents an
early failure rate which would be admirably low even in
2005.
Dr Scribner from Seattle was the first nephrologist to
refer one of his patients to New York for the creation of
an AV fistula.

12.  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

13.  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.

15. 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.

17. Conventional types of Upper
Arm AVF

22.  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.

24.  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

26.  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.

27. 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.

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. 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.

31. • 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

33. 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

34. Accessory veins
 The presence of the cephalic vein without problems in the arm allows a
good development of AVF.
 However, the cephalic vein, in a significant number of patients, may have or
possess several accessory veins.
 This is not a problem, and may be advantageous because it enables the
development of multiple venous punctures.
 However, when blood flow is lower than should be, the AVF maturation can
present problems.
 The accessory veins “deviate” from the main vein blood flow, promoting the
reduction of flow and pressure in this vein, that is crucial to occur the
natural thickening and arterialization of the used vein. vessel.

35.  The accessory veins can be easily identified by physical
examination,
 Usually, these can be seen by looking through the
existence of numerous veins or detected by palpation.
 To identify the existence of accessory veins, it should
be made the technique described by Beathard:
 palpate the thrill under the anastomosis, mobilize the
fingers along the vessel until the presence of accessory
veins, and at that site make manual finger pressure to
“obstruct” the flow.
 After this obstruction, we perform palpation of the
thrill above the occlusion.
 If the thrill does not disappear above the drainage vein
occlusion, it is a sign that the “deviation” flow occurs
below the point of occlusion.

37. Thank you