Av fistula examination dr tarek aleraky

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

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 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 disappear above the drainage vein occlusion,
it is a sign that the “deviation” flow occurs below the point of
occlusion.

37. Thank you