verbeeck-_Opmaak 1 21/10/11 10:41 Pagina 266

JBR–BTR, 2011, 94: 266-277.

DIALYSIS ARTERIOVENOUS FISTULAS: THE CRITICAL ROLE OF COLOR

DOPPLER ULTRASOUND
N. Verbeeck1, F. Prospert2, D. McIntyre3, S. Lamy3

Despite being time-consuming and observer-dependent, CDUS is a method of choice for performing and controlling
dialysis shunts. It contributes to increasing the number of native AVFs and enables early detection of lesions there-
fore allowing quick percutaneous or surgical therapy.

Key-words: Ultrasound (US), Doppler studies – Fistula, arteriovenous.

The aging of the population

induces an increase of the occur-
rence of vascular and metabolic dis-
orders with an impact on renal func-
tion, such as arterial hypertension or
diabetes. In the USA, the prevalence
of end-stage renal disease (glomeru-
lar filtration rate lower than
15 mL/min/1.73m²) doubled during
the last decade of the twentieth cen-
tury; in 1998, slightly more than one
American per thousand was suffer-
ing from total renal failure. A third of
these patients were treated by renal
transplantation and two thirds by
hemodialysis (1, 2). The amount of
hemodialysis patients worldwide
rose from 400,000 in 1990 to
1,100,000 in 2000 with a current esti-
mation of more than 2,000,000 (3).
The type of treatment of end- A B
stage renal disease depends on the
patient’s status, the etiology of the
disease and the possible associated
illnesses. Renal transplantation is of
course the treatment of choice but it
is not always feasible. When
hemodialysis proves necessary, it is
ideally performed after construction
of a native radiocephalic arteriove-
nous fistula in the nondominant
forearm, a method introduced by
Brescia and Cimino in the USA in
1966 (Fig. 1A). Native brachiocephal-
ic fistulas at elbow level develop
more easily than their counterparts
in the forearm but, beside the fact
that they are shorter lived, they
induce excessive blood flows more
often, generate more distal
ischemias and transform into
aneurysms more frequently (4, 5). C
Peritoneal dialysis can be suggested
as an alternative mode of therapy, Fig. 1. — Diagram showing native radiocephalic fistula (A) and prosthetic shunt (B)
namely for children or patients with with the dialysis needles in place (source: Mayo Foundation for Medical Education and
Research). C. Photograph: Hickman double lumen catheter with cross section view.
a poor cardiac function, but its use is
unfortunately limited in time (6). The
polytetrafluoroethylene (PTFE) arte-
riovenous graft introduced as early
as 1976 (Fig. 1B) is a second choice
since it implies a higher amount of
From: 1. Dpt of Radiology, 2. Dpt of Nephrology, 3. Dpt of Urology, Centre Hospitalier
de Luxembourg, rue Barblé, 4, L-1210 Luxembourg, Grand Duchy of Luxembourg. pernicious thrombotic and infectious
Address for correspondence: Dr N.Verbeeck, M.D., Service de Radiologie, Centre events (7, 8, 9). For reasons beyond
Hospitalier de Luxembourg, rue Barblé, 4, L-1210 Luxembourg, Grand Duchy of the scope of our article, the arterio-
Luxembourg. E-mail : [email protected] venous graft has remained the most
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DIALYSIS ARTERIOVENOUS FISTULAS — VERBEECK et al 267

Diagram 2: upper limb arteries: 1. aortic

arch, 2. brachiocephalic artery, 3. left Fig. 4. — Diagram showing fistula
Fig. 3. — Upper limb veins: 1. superior drawing following CDUS.
common carotid artery, 4. left subclavian vena cava, 2. brachiocephalic vein, 3.
artery, 5. right common carotid artery, 6. innominate vein, 4. left subclavian vein,
right subclavian artery, 7. right axillary 5. right internal jugular vein, 6. left inter-
artery, 8. right brachial artery, 9. right nal jugular vein, 7. right subclavian vein,
radial artery, 10. right ulnar artery, 11. pal- 8. right axillary vein, 9. right cephalic
mar arches. vein, 10. right basilic vein, 11. right super-
ficial radial vein, 12. right superficial
ulnar vein (dotted lines: deep veins of the
forearm).

widely used method of dialysis in

the United States even though,
thanks to the Kidney Disease
Outcomes Quality Initiative (KDOQI),
the tendency is presently reversing
in favor of native fistulas (10). The
double lumen dialysis catheter
(Fig. 1C) devised by R.O.Hickman in
1979 already, should, apart from a
limited use, only be considered as a
very last solution. Its infectious and
thrombotic complications are indeed
extremely frequent (11).
Presently, a native shunt is the Fig. 5. — brachial artery triplex: optimal angle, gate size, PRF,
focalization and gains.
superior option. Japanese physi-
cians have understood it correctly
since they dialyze 90% of their
patients via a Brescia-Cimino fistula.
Their European counterparts follow served in order not to compromise Indications for CDUS before the cre-
close with 80% of their hemofiltra- the possible later construction of a ation of a native shunt
tions via a native arteriovenous fistu- hemodialysis access (11).
la (AVF) whereas their American col- In this article, we will demonstrate Since a native dialysis AVF
leagues are progressing: 25% of the exceptional role of color Doppler requires maturation over several
native AVFs in 2001 and the figure is ultrasound (CDUS) in preparing the weeks before it can be punctured,
steadily increasing (12). Let us stress site for dialysis AVFs and for their when the renal disease reaches
here that, since the start of renal follow-up. The examination indica- stage 4 (glomerular filtration rate
pathology and whatever the treat- tions and the technical modalities for between 15 and 29 mL/min/1.73m²)
ment selected, the patient’s venous the use of CDUS have been kept and even earlier if the disease devel-
capital must by all means be pre- separate for clarity of presentation. ops more rapidly, the patient is
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268 JBR–BTR, 2011, 94 (5)

A
Fig. 6. — A: triplex, with a low frequency abdominal probe, of
B
a normal right subclavian vein: cardio-respiratory modulation of
the flux (arrows).
B: left side: occlusion of the innominate trunk with demodula-
tion of the subclavian flux (arrows).
C: angiographic proof of the occlusion (arrow), due to a dialy-
sis catheter. The stars indicate the collateral network.

referred to the vascular surgeon for

a clinical examination of their upper
limb vessels (11). If arteries and
veins appear suitable for the con-
struction of an AVF, the shunt is cre-
ated without any further examina-
tion (13). Should the vascular struc-
tures seem suboptimal, the patient
must be referred to a radiologist for
CDUS assessment. Obese, female,
elderly, diabetic patients as well as C
those suffering from cardio-vascular
disorders will derive the greatest
benefit from CDUS assessments (11,
14). Patients with Raynaud’s syn-
dromes, thoracic outlet syndromes A clinical inspection of the fistula of stenoses that do not appear at
and those with a history of previous at each dialysis session is a first clinical examination or that do not
central vein catheter should also stage in the surveillance program. infer a significant decrease in the
benefit from CDUS assessments (15) Venous collapse, decreased thrill, dialysis outflow (8, 23, 24). The fact
even more as this noninvasive and edema in the limb are some warning that the fistula outflow, as well as the
widely available imaging is not signs. coronary arteries flow, only starts
expensive (16). It remains, neverthe- The second stage of surveillance dropping when the shunt diameter is
less, time-consuming and observer- is the control of dialysis physico- considerably reduced (25), also
dependent (17). chemical parameters. Any distur- advocates for a systematic control.
Preoperative CDUS not only helps bance in the arterial or venous pres- Therefore, in our institution, we per-
to increase postoperative and pri- sures in function of the flow, of the form an annual CDUS for each dialy-
mary patencies in native fistulas (18, urea reduction rate and of the recir- sis patient even if no abnormality is
19), it also increases the number of culation rate must be noticed (2). assessed during their dialysis ses-
native shunts versus PTFE Some dialysis centers are equipped sions. Other authors think that such
grafts (20). with validated instruments linked examination is not relevant since the
directly to the hemodialysis network detected lesions are not meaning-
Indications for CDUS in the surveil- to measure the access blood flow by ful (26). KDOQI does not recommend
lance of AVFs dilution technique. Any abnormal any time limit and advises to pro-
value should be noted (21, 22). ceed on a case by case basis (2). We
Surveillance of dialysis shunts CDUS is the third stage of surveil- do not think, however, that the cost
aims principally at lowering the fre- lance. It is recommended when the of a yearly CDUS is unacceptable
quency of fistulous thromboses fistula reveals a clinical problem or considering the total annual cost of
whose consequences on the when the dialysis parameters are dialysis or that of a fistulous throm-
patients’ morbidity and mortality are altered (2). Some authors also bosis.
well-known and which entail impor- advise to perform routine CDUS on Even if some authors consider
tant additional costs (2). the pretext of allowing the detection angiography as the gold standard in
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DIALYSIS ARTERIOVENOUS FISTULAS — VERBEECK et al 269

A Dist 0.031 cm

Fig. 8. — B-mode of a normal intima-media thickness: meas-

urement between the “inner surface” and the first anechoic line.

B Fig. 9. — Color Doppler of an upper brachial branching at the

level of the mid-humerus (H): the ulnar (U) and radial (R) arter-
ies, the brachial vein (V).
Fig. 7. — A: triplex at the level of an ostial cephalic vein steno-
sis: obvious acceleration, without aliasing thanks to the 5 MHz
probe, at 4.5 m/s.
B: angiographic counterpart: cephalic vein (white arrow)
stenosis (black arrow), stars indicate the subclavian and innom-
inate veins.

assessing dysfunctioning dialysis

fistulas (2, 22, 27), we think that
CDUS, possibly linked with magnet-
ic resonance (MR) angiography (cf
infra), remains largely sufficient and
we keep iodinated contrast
enhanced controls for cases requir-
ing percutaneous therapy.

Indications for CDUS in case of

immature AVFs

If a prosthetic arteriovenous graft Fig. 10. — Triplex showing the effect of the releasing (arrow) of
can be used soon after its creation, it a brachial tourniquet on the radial arterial spectrum: the resis-
is advisable to allow native AVFs to tive index drops to 0.65 (white circle), a good predictive factor
before AVF creation.
mature over a period of about six
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270 JBR–BTR, 2011, 94 (5)

Fig. 11. — B-mode of the internal lumen of a radial artery (thick Fig. 13. — Triplex of a cephalic vein with a flow measurement
arrow). The measurement (2 mm, thin arrow) indicates that the (arrow): appropriate setting of angle, PRF and vessel diameter;
prognosis of the shunt is good. 4 cardiac cycles are taken into account.

Fig. 12. — B-mode of a favorable distensibility test: increase of

the venous diameter (thick arrows) by 50% (thin arrow) after
brachial tourniquet.

weeks before initiation of hemodial- Fig. 14. — Color Doppler of an AVF anastomosis (arrow): the
ysis (28). Successful fistula matura- stardust artifact (stars).
tion, which translates into a fitting
increase of the vein caliber, results
from a clear increase of its flow (29).
It is easier for brachiocephalic AVFs
than for radiocephalic anastomoses quick and frequent phenomena of ture site, limiting the number of
but the latter remain preferable restenosis (4, 31). Later on the fistula punctures and, more generally,
mainly because of their greater will ‘calm down’ and ensure its dura- reducing the duration of the inter-
longevity (5). Since radiocephalic bility (5). vention (16).
AVFs tend to reach their maximum
flow at 4 weeks (30), a clinical Indications for CDUS prior to thera- Indications for CDUS per- and post-
inspection of the shunt is recom- py surgical or percutaneous treatment
mended one month after its con-
struction. If the draining vein is badly It is up to the radiologist or to When the immature AVF of a
or not palpable, an assessment the surgeon to decide whether or patient preparing for dialysis with
CDUS should be carried out to not to have CDUS performed before impaired renal function must be
define the reason of its lack of matu- treating a dialysis fistula. Individual treated, it is to be advised to limit the
ration (cf infra) (8, 10). practices vary, however advantages exposure to nephrotoxic iodinated
Once it has been treated, the vein of pre-intervention CDUS include contrast material. Iodine dilution is a
must be closely monitored due to optimizing the selection of the punc- first solution; a smart alternative
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DIALYSIS ARTERIOVENOUS FISTULAS — VERBEECK et al 271

probe, around 10 MHz, should be

used (7).
The US unit must be used at full
capacity, i.e. in the triplex mode,
associating the brilliance mode (B),
the color Doppler mode and the
pulsed Doppler mode with an angle
of insonation between 30 and 60° in
order to avoid an alteration of the
velocity measurements (32).
The study in B-mode is carried
out, after an appropriate gain adjust-
ment, on both planes of the vessels,
particularly for veins whose diame-
ter is often ellipsoidal. Venous ele-
ments should moreover be exam-
A ined by using a gentle transducer
pressure. Let us not forget that the
upper limb is arterially fed by the
brachial artery via the subclavian
artery then the axillary artery. The
brachial artery most often divides, at
elbow level, into a radial artery and
an ulnar artery, which anastomose at
the hand (Fig. 2). Venous draining of
the upper limb rests on a deep net-
work and a superficial one, linked by
perforating vessels. The deep net-
work borders the arterial system
with, generally, two veins for each
artery. The superficial structure con-
sists, though there exist many
anatomical variations, of a radial
vein and an ulnar vein that anasto-
mose at the elbow joint to give a
cephalic vein and a basilic vein
drained respectively by the subcla-
vian and the axillary systems. The
central return pathway occurs along
the superior vena cava, via the
innominate trunk on the left (Fig. 3).
B C Pulsed Doppler spectral analysis
is performed with an optimal adjust-
Fig. 15. — A: triplex of arterial stenoses: color aliasing and obvious acceleration at ment of the gain, of the repetition
more than 3 m/s (arrow). frequency and of the gate size, ideal-
B: angiographic correlation: post-ostial radial artery stenoses (thick arrow) and post- ly two thirds of the examined vessel
anastomotic venous stenosis (thin arrow). (Fig. 5).
C: the fistula after percutaneous treatment. The study of central veins
remains a problem for sonogra-
phers. If the superior vena cava and
the innominate trunk are completely
out of reach because of aeric and
osseous interpositions, their perme-
consists in partially or totally assess- General CDUS technique for upper ability can be checked indirectly.
ing the therapy (dilatation, throm- limb vessels Indeed, in the case of an important
bolysis…) by CDUS without any vas- stenosis or thrombosis, the cardio-
cular opacification. CDUS examination can be respiratory modulations of the sub-
Besides, CDUS can prove useful performed on a seated patient (8, 15) clavian veins disappear (Fig. 6). In
in the operating room when the sur- but we prefer, like obese patients, a direct study of sub-
geon performs a banding of an J.M. Corpataux (29), to perform the clavian veins will prove complicated
excessively high flow fistula. The study in the supine position, as if a high-frequency transducer is
radiologist can then measure the much for the patient’s comfort as used. Some advocate then to resort
flow repeatedly in order to guide the for the radiologist’s. The bare- to MR or CO2 angiography to spot
extent of vein caliber reduction. breasted patient will be installed in a stenoses (11, 15, 27). In our experi-
Finally, CDUS cannot be ignored room with a minimum temperature ence, we almost never resort to MR
for the post treatment check-up and of 20°C (15) and the ultrasound imaging. Whenever confronted with
for the long term surveillance of the gel should be slightly warmed and difficult cases, we use low-frequency
treated fistulas that prove potentially spread liberally (10). Most authors abdominal transducers. If their spa-
frail. admit that a high-frequency tial resolution is lower than that of
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272 JBR–BTR, 2011, 94 (5)

Fig. 16. — Arterial stenosis triplex: downstream SUT increase Fig. 17. — Radial steal triplex, the wrist being at left, the elbow
at 160 ms (arrow). at right: blood flow is in the direction of the probe, via the pal-
mar arches.

high-frequency probes, the draw-

back is balanced by a reduced sensi-
tivity to absorption and, mainly, by a
lower susceptibility to phenomena
of frequency ambiguity, so much so
that the accelerated specters of
stenosed veins can be optimally
studied (32) (Fig. 7).

CDUS technique before AVF creation

As it has been explained above, a

pre-AVF CDUS must be performed
when clinical examination of the
upper-limb vessels is inconclusive. It
starts with a study of the arterial net-
Fig. 18. — B-mode of an ulnar artery (thin arrow) with an anas-
work where it must exclude any tomotic stenosis (thick arrow).
stenosis that would be revealed in
B-mode by a reduction in vessel
diameter and in Doppler mode by a
maximum local velocity increase of
more than twice the median systolic
velocity of the artery. The intima-
media thickness, which must be
under 0.6 mm, is measured at the far mapping, examining very closely the CDUS technique and criteria for nor-
wall of the vessel and possible calci- permeability of the central veins, mal AVFs
fications are spotted (Fig. 8). In the which may be confirmed by MR
instance of elbow fistulas mainly the angiography assessment. The thick- Except when an extensive throm-
absence of upper brachial bifurca- ness of the walls is recorded and the bosis is suspected, the examination
tion must be checked since it is a examiner will verify that, for native should not be carried out right after
source of future dysfunctioning (Fig. wrist AVFs, the draining vein has a dialysis. Indeed, flow calculations
9). A hyperemia test must be carried diameter of at least 2 mm. Venous can be wrong owing to reduced
out and allows checking the ade- distensibility is measured by the blood volume (2). Moreover, if the
quate reactivity of the arterial sys- tourniquet test: ideally, the diameter examination is performed immedi-
tem: after releasing a brachial tourni- of the vein must have increased by ately following hemodialysis, impor-
quet fastened during two minutes, 50% after a two-minute application tant vascular segments may be hid-
the resistive index (S-D/S, automatic (11, 14) (Fig. 12). den under the dressing and it will
calculation) must be lower than 0.7 The examination report is usefully prove challenging for the echo
(14) (Fig. 10). Finally, in the case of accompanied by a diagram, even by Doppler to make a distinction
wrist fistulas, the minimum luminal skin marking (15). We acknowledge between post-puncture spasms and
diameter of the radial or ulnar artery this practice may not be practically actual stenoses.
must ideally be equal to or higher feasible in all cases but we aim to The absolute criterion for a well
than 2 mm (11) (Fig. 11). perform the examination in the pres- functioning dialysis fistula is that it is
The exploration of the venous ence of the vascular surgeon who able to undergo at least six dialysis
system starts with a thorough will construct the anastomosis. sessions a month and sustain a
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DIALYSIS ARTERIOVENOUS FISTULAS — VERBEECK et al 273

A
Fig. 19. — A:Triplex of a cephalic vein stenosis: color aliasing
and spectral acceleration up to 6 m/s (arrow).
B: angiographic confirmation of the stenosis (arrow).
C: the same vein after percutaneous dilatation. C

350 mL/min for the dialysis device

and 150 mL/min to keep the fistula
patent during hemodialysis ses-
sions. The minimum blood flow in a
graft is 650 mL/min and we agree to
say that it must be at least 750
mL/min in a native arm fistula (2).
The fistula blood flow should always
be recorded in the report and will be
the standard for all further CDUS as,
whatever the cause of AVF dysfunc-
tion, any drop of more than 20% in
the fistula blood flow by comparison
with a former normal examination
must be considered suspicious and
lead to a more thorough study of the
fistula, even to a closer surveillance
(11).
Let us note that findings of
Fig. 20. — B-mode of a venous aneurysm (star) with partial colored tissular signals in the region
parietal echogenic clotting (arrows).
of the anastomosis are quite normal
and are called stardust artifact. They
appear on all AVFs and are a result of
vibration phenomena (Fig. 14).
blood flow rate of 350 mL/min (8) or Flow measurements are said to CDUS criteria of AVF disorders
– more prosaically – that it ensures a be taken on the feeding artery (2, 34)
sufficient flow for hemodialysis (11), but we actually check arterial and Lesion therapy modalities are
which can perfectly be confirmed by venous flows, with necessarily an mentioned because we consider
CDUS. The AVF CDUS must examine angle of insonation between 30 and they are significant for AVF follow-
the whole shunt in triplex mode. We 60°. Three to four cardiac cycles are up, even if the radiologist is not
follow Franco and the KDOQI guide- taken into account and turbulence interventional.
lines and use easy echo Doppler areas are avoided (8). The blood flow
criteria, based on figure 6, that indi- is calculated automatically by recent Cardiac pump problem
cate a healthy shunt: 6 weeks after machines by using the classical for-
surgery, the fistula flow volume mula: outflow (in mL/min) = average It is quite evident that a left car-
must be at least 600 mL/min and the blood velocity x (πD²/4) x 60, where D diac failure or an aortic valve steno-
diameter of the draining vein, at a represents the vessel diameter in cm sis may induce a flow drop in the
maximal depth of 6 mm, must be (Fig. 13). Let us insist on the fact that, dialysis AVF. Such very central
greater than 6 mm. Another criterion even if they are done by an experi- lesions will be diagnosed thanks to
of adequacy must be added to this enced examiner, Doppler measure- the concomitant demonstration of a
list of basic criteria: the length of the ments of the blood flow have a mar- systolic upstroke time (SUT)
venous segment that is punctured gin of error of 5% (35). The minimum increase in both the fistula and the
must equal 10 cm or twofold blood flow rate in a wrist AVF must arterial sectors that are not included
4 cm (33). ideally be 500 mL/min, i.e. in the shunt (36). The treatment of
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274 JBR–BTR, 2011, 94 (5)

Fig. 21. — B-mode of a variable echogenicity perivenous Fig. 22. — Color Doppler of an anechoic seroma (star) gener-
hematoma (red arrows) entailing a venous stenosis (white ating a post-anastomotic venous stenosis (arrow).
arrow).

these pump problems is medical, Arterial steal zation of a more than 50% narrowing
even cardio-surgical. of the vascular caliber and of higher
The steal syndrome is due to a
local velocities together with or with-
diversion of the arterial flow intend-
Stenosis of the subclavian artery out a decreased flow (Fig. 19). Let us
ed for the limb towards the draining
not forget that central venous
In most cases, Doppler echogra- vein of the fistula. Due to an exces-
stenoses prove technically challeng-
phers cannot reach the ostium of the sive flow rate or to a stenosis of the
ing to analyze.
subclavian artery. A diagnosis of feeding artery, the flow of the post-
The treatment of venous stenosis
stenosis is then based on the SUT of anastomotic artery is reversed, fed
is identical to that of arterial narrow-
the subclavian artery at the level of by the palmar arches in the forearm
ings except that the endoprostheses
the clavicle. The problem is that the AVFs and by deep lying collaterals in
that may be used must be self-
arteriovenous anastomosis itself the case of brachial shunts (Fig.17).
expanding (9). If the fistulous flow
implies a SUT increase. A correct The intensity of the reversal may
rate is abnormally high in spite of a
measurement of this value can be vary, similarly to the subclavian
venous stenosis, the latter must be
obtained by a simple gesture that steals (32, 38), and the phenomenon
monitored carefully but should not
consists in shutting the post-anasto- rarely has a clinical impact (2-
be treated in order to avoid exces-
motic vein manually during some 6%) (7). If it causes distal ischemic
sive flow and a pernicious impact on
seconds. symptoms, a surgical or interven-
the heart function.
A lower than 70 millisecond SUT tional radiologic treatment can be
must be rated as normal (extrapolat- suggested (9).
Distal ischemia
ed from 36).There is no pathological
threshold, as far as we know, above Anastomotic stenoses Distal ischemia is the result of a
this value but a subclavian ostial serious steal syndrome, of a severe
stenosis must be suspected if the B-mode sonography displays the arterial stenosis or of a venous
SUT is noticeably higher than the narrowing directly whereas the stenosis considered sufficient to cre-
mean SUT in the arteries of the neck, Doppler mode pinpoints an increase ate an upstream increase in pres-
the contralateral upper limb and the of the systolic velocity with local tur- sure (39). Various etiologic factors
lower limbs. bulence, a flow drop and, in the color can of course be associated and can
mode, an enhanced stardust artifact all be detected by CDUS.
Arterial stenosis (Fig. 18). The treatment of distal ischemia
Anastomotic stenoses are gener- proves delicate. It derives benefit
The indirect Doppler criterion for ally viewed as the result of a techni- from surgical techniques as well as
a significant arterial stenosis is a cal error when they are detected from radiological interventions (9).
flow drop. soon after AVF construction and
Direct criteria, in B-mode, consist must be managed surgically (37). Arteriovenous aneurysms and
in a higher than 50% decrease of the
pseudoaneurysms
endoluminal arterial diameter and, in
Venous stenosis
pulsed-wave mode, in a twofold The literature on arteriovenous
increase of the mean systolic velocity Repeated punctures as well as aneurysms and pseudoaneurysms
(Fig. 15) together with an increase of vibrations and turbulences caused remains limited. Their diagnosis
the downstream SUT (Fig. 16) (16). by the shunt contribute to the devel- rests on direct echographic visualiza-
In case of tight stenosis, percuta- opment of venous stenoses. They tion. They are characterized by a
neous transluminal angioplasty, pos- are the result either of a fibrosis or of diameter more than twice that of the
sibly together with a metallic endo- an endothelial hyperplasia that can adjacent normal fistula and can
prosthesis fixed on a balloon, is the affect valvular zones (9, 16). Their show a more or less intense parietal
therapeutic treatment of choice (37). diagnosis rests on the direct visuali- clotting that is potentially throm-
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DIALYSIS ARTERIOVENOUS FISTULAS — VERBEECK et al 275

etiology list is not exhaustive (7).

Fistulous occlusion, whether it is
incomplete or total, poses a threat
since it induces severe endothelial
alterations that put the longevity of
the fistula at risk, even after a rapid
intervention (2).
The treatment of a complete
B thrombosis can be performed by a
surgeon or by an interventional
A radiologist (thrombolysis) and the
removal of the possible mechanical
obstacle must happen at the same
time.

AFV nonmaturation
Let us remember that, when clini-
cal doubt arises as to fistulous matu-
ration, CDUS should be performed
as soon as four weeks after fistula
construction. AVF nonmaturation is
revealed by an absence of develop-
C ment of the draining vein six weeks
after shunt creation (28). It is mainly
Fig. 23. — B-mode of venous clottings (long arrows and star)
with variable echogenicity. The short arrow in figure 19B shows
the result of stenosing arteriovenous
slightly echogenic low speed residual blood flow. lesions or of an excess of collaterals
in the venous section. These causes
are easily detected sonographical-
ly (33, 42). Excess of superficial or
perforating collaterals on the drain-
ing vein implies a rapid decrease of
the fistulous venous flow and hence-
forth dialysis problems. Surgical lig-
ations are apt to solve the problem.
Fistulous immaturity always
requires an emergency treatment
since the thrombosis occurs early
and the shunt proves extremely diffi-
cult to reopen (4).
What is called maturation pseudo
delay is the result of an excessive
depth of the draining vein, more
than 5 to 6 mm from the skin surface
whereas the other characteristics of
Fig. 24. — Color Doppler of a maturation pseudo delay: the the AVF remain normal. This abnor-
vein (in blue) is situated too deep, i.e. 8 mm, to be easily punc- mal depth is clearly demonstrated in
tured (arrow and white circle).
B-mode and makes puncture for
dialysis quite arduous (Fig. 24). It
requires surgical treatment consist-
ing in a venous transposition with
possible resection of fatty tissues.
bogenous and emboligenous The treatment of such mass syn-
(Fig. 20). dromes is medical, even surgical Excess flow
They require surgical treatment, when the lesion is severe and poten-
When the diameter of the anasto-
particularly if they develop rapid- tially associated with a pernicious
mosis is excessive, it no longer plays
ly (40, 41). stenotic effect for the function of the
its role as a natural brake and the fis-
fistula.
tulous function races out of con-
Hematoma, seroma, abscess
trol (9). CDUS does display the phe-
Thrombosis
They are often the result of diffi- nomenon whether in B-mode or in
cult venopunctures and are directly Fistulous thromboses are opti- Doppler mode where the flow meas-
visualized by echography which, in mally visualized by B-mode sonogra- urement is abnormally high (Fig. 25).
this field, is significantly more effi- phy under the form of endovascular It is estimated that a higher than 2 L
cient than angiography (7). B-mode material displaying a variable fistula flow is, owing to complex
shows a variable echogenicity struc- echogenicity and whose hardness is mechanisms, potentially pernicious
ture with a more or less thick wall, even more patent as it is detected for the cardiac function (9). An
potentially responsible for a com- late (32) (Fig. 23). They can be caused excessive fistula flow can also trig-
pressing impact on the draining vein by sudden hypotension, dehydration ger a distal ischemia by steal as we
(Fig. 21, 22). or even a tight venous stenosis, the have already explained.
verbeeck-_Opmaak 1 6/10/11 13:49 Pagina 276

276 JBR–BTR, 2011, 94 (5)

and long-term implications. J Am Soc

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5. Turmel-Rodrigues L.: Nonmaturating
fistulas. Angio Access for
Hemodialysis. Tours, France, June
2010 (www.sfav.org).
6. The National Kidney Foundation
Kidney Disease Outcomes Quality
Initiative, Clinical Practice Guidelines
for Peritoneal Dialysis Adequacy,
Update 2006 (www.kidney.org).
7. Finlay D.E., Longley D.G.,
Foshager M.C., et al.: Duplex and
color Doppler sonography of
hemodialysis arteriovenous fistulas
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Fig. 25. — Triplex of an excessive AVF outflow at 2.4 L/min. 983-989.
8. Robbin M.L., Chamberlain N.E.,
Lockhart M.E., et al.: Hemodialysis
arteriovenous fistula maturity: US
Excess flow requires an elaborate (Fig. 4) illustrating the abnormalities evaluation. Radiology, 2002, 225: 59-
surgical treatment, starting from lig- we have discovered. We are con- 64.
9. L’abord vasculaire pour hémodialyse.
ations and arterial transpositions up vinced that the diagrams prove most Association Française des
to closure of the AVF in the most helpful for the whole staff to under- Infirmier(e)s de Dialyse,
serious cases (9, 43). stand the anatomical and functional Transplantation et Néphrologie. Paris,
particularities of these shunts, con- Editions Masson, 2004.
sequently improving the long-term 10. Singh P., Robbin M.L., Lockhart M.E.,
Prosthetic graft fistulas et al.: Clinically immature arteriove-
prognosis of difficult dialysis fistu-
las. nous hemodialysis fistulas: effect of
We have less experience with US on salvage. Radiology, 2008, 246:
prosthetic graft fistulas. They are 299-305.
Conclusion
constructed in the arm essentially, 11. Tordoir J., Canaud B., Haage P., et al.:
most often with PTFE prostheses EBPG on vascular access. Nephrol
Though it is time-consuming and Dial Transplant, 2007, 22: 88-117.
and practically do not require a peri-
observer-dependent, CDUS is an 12. Bourquelot P.: Histoire de l’abord vas-
od of maturation (9). We have
available and rather affordable culaire. Cours-Congrès Ajaccio,
already underlined the fact that
method of choice for the construc- France, 2008 (www.sfav.org).
native AVFs must be preferred to 13. Nursal T.Z., Oguzkurt L., Tercan F., et
tion and the surveillance of dialysis
prosthetic grafts since the latter are al.: Is routine preoperative ultrasono-
shunts. It is particularly efficient,
more prone to thrombosis, most graphic mapping for arteriovenous
mainly in experienced hands, and
often due to a stenosis of the venous fistula creation necessary in patients
contributes to increase the number
anastomosis, but they are some- with favourable physical examination
of native AVFs. Besides, it enables to findings? Results of a randomized
times the only solution left for
detect lesions quite early and allow a controlled trial. World J Surg, 2006,
hemodialysis. Anyway, they are a
quick percutaneous or surgical ther- 30: 1100-1107.
better choice than central
apy resulting in a greater efficiency 14. Ferring M., Henderson J., Wilmink A.,
catheters (14).
and a longer sustainability of dialy- et al.: Vascular ultrasound for the
CDUS indications for vascular pre-operative evaluation prior to
sis shunts.
dialysis grafts keep to the same prin- arteriovenous fistula formation for
Our policy is to perform CDUS as
ciples as those mentioned for native haemodialysis: review of the evi-
soon as a clinical problem or a diffi-
AVFs. Careful attention must be paid dence. Nephrol Dial Transplant, 2008,
culty arises during dialysis. Our
to the analysis of that sensitive area 23: 1809-1815.
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covering the junction between the
an annual CDUS assessment but we veineuse et artérielle. Cours-Congrès
prosthesis and the vein.
examine them more often in case of Ajaccio, France, 2008 (www.sfav.org).
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Report
par échographie. Cours-Congrès
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Next to an exhaustive anatomical References 17. Malovhr M.: Pre op imaging: how to
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