Cephalic vein and hemodialysis fistula: surgeon's observation versus color Doppler ultrasonographic findings.

Abstract

The aim of this study was to evaluate whether preoperative color Doppler ultrasonography improves immediate success rates of arteriovenous fistulas for dialysis. One hundred twenty-four patients with chronic renal failure underwent color Doppler ultrasonographic examination of both arms, including the cephalic vein, before arteriovenous fistula construction. Patients were randomly divided into 2 groups: A and B. In group A, there were 52 patients, and the surgeon planned to construct arteriovenous fistulas depending only on physical examination. In group B, which comprised 72 patients, surgeons performed arteriovenous fistula construction on sites labeled by color Doppler ultrasonography. In group A, of 52 patients who had surgery for arteriovenous fistula construction, 13 had fistulas that did not function. Among these 13 patients, 8 were found to have chronic thrombotic changes in the cephalic vein on color Doppler ultrasonography, and 5 had none of these changes. When we checked the color Doppler ultrasonographic findings, we noted that these 5 patients had decreased volume flow in the radial artery. On the whole, the arteriovenous fistulas worked in 39 patients (75%) and did not function in 13 patients (25%). In group B, surgeons followed the color Doppler ultrasonographic results. Of 72 patients who underwent the procedure, 68 patients (94.4%) had functioning fistulas, whereas 4 (5.6%) had fistulas that did not work. These 4 patients were found to have low volume flow in the radial artery. When both groups were compared by chi2 analysis, the difference was statistically significant (P = .002). Group B, in which patients were preoperatively evaluated by color Doppler ultrasonography, had a high success rate. We found that color Doppler ultrasonography is very helpful as a noninvasive procedure for this evaluation. Although many surgical clinics still perform arteriovenous fistula construction without the aid of color Doppler ultrasonographic findings, we think that the use of color Doppler ultrasonography should be emphasized before surgeons proceed with arteriovenous fistula construction.

Routine Preoperative Vascular Ultrasound Improves Patency and Use of Arteriovenous Fistulas for Hemodialysis

“…Our finding that immediate failure is significantly reduced by preoperative ultrasound is consistent with another randomized trial, which showed significantly less failure (6% versus 25%) on the day of surgery in the ultrasound compared with the clinical group (19). Inadequate vessels can be identified by ultrasound, which reduces the rate of immediate failure (11,12,24).…”

The Combination of Sonography and Physical Examination Improves the Patency and Suitability of Hemodialysis Arteriovenous Fistula in Vascular Access

“…Perhaps vascular (ultrasound) mapping provided more objective assessment of the cephalic vein until the axillary vein. In our study, the ultrasound mapping not just the size of the vessels but also its depth and presence of stenosis similar to a report elsewhere (12).…”

“…The inability to maintain the benefit of using preoperative ultrasound mapping could be due to failure caused by various factors such as thrombosis or stenosis of the venous limb due to multiple puncture or stenosis at the juxtaarterial anastomosis. Similar finding was reported by I. Mihmanli et al, where they concluded that preoperative duplex US scanning improved short-term AVF patency, from 75% to 94%, compared with physical examination alone (8).…”

“…Silva et al compared access outcome in 172 patients undergoing preoperative venous mapping with historical controls and showed that the routine preoperative ultrasound increased the prevalence of native access from 14 to 63% (p < 0.05) (10). Another prospective study evaluating the effect of preoperative ultrasound by Mihmanli et al used randomised study design where 124 patients undergoing assessment for fistula into preoperative physical examination alone or evaluation with ultrasound alone showed benefit of using ultrasound during AV fistula creationthe rate of primary non-functioning was only 5.6 % in the ultrasound group compared with 25% in patients undergoing physical examination (8). A study by Allon et al found that the proportion of fistulas placed increased from 34% during the historical control period to 64% with preoperative vascular mapping (P < 0.001) (11).…”

Current Management of Vascular Access

“…In selected patients, additional imaging is indicated to exclude the presence of central vein stenosis or thrombosis. A dramatic increase in fistula placement was observed by several centers after implementation of routine preoperative vascular mapping (2,7,9,(25)(26)(27)(28). Among patients who are referred for their initial vascular access surgery, placement of a forearm fistula is feasible in only 40 to 50% (2,3,7,9).…”