Measuring the palpable pulsatility length as a physical examination test in defining the severity of inflow stenosis for hemodialysis fistulas

Abstract

Background Pulsatility is an important property of hemodialysis arteriovenous fistulas (AVF) and can be perceived by the fingers as a gradual decrease in strength downstream from the anastomosis along the main trunk of the fistula. The distance from the point at which the pulse becomes imperceptible to the anastomosis is termed the palpable pulsatility length (PPL); we considered this length may play a role in assessing the severity of inflow stenosis for hemodialysis fistulas. Methods This study was performed by retrospective analysis of routinely collected data. Physical examinations and fistula measurements were performed in a selected population of 76 hemodialysis patients with mature fistulas during half a year. Fistula measurements included the PPL before and after treatment and the distance between the anastomosis and the arterial cannulation site (aPump length). The aPump index (API) was calculated by dividing the PPL by the aPump length. Angiograms were reviewed to determine the location and severity of stenosis. PPL and API were used to detect the critical inflow stenosis, which indicates severe inflow stenosis of an AVF. Results Receiver operating characteristic analysis showed that the area under the curve was 0.895 for API and 0.878 for PPL. A cutoff value of API < 1.29 and PPL < 11.0 cm were selected to detect the critical inflow stenosis. The sensitivity was 96.0% versus 80.0% and specificity was 84.31% versus 84.31% for API and PPL, respectively. Conclusions PPL and API are useful tools in defining the severity of pure inflow stenosis for mature AVFs in the hands of trained examiners with high sensitivity and specificity.

An eighth note

“…The eighth note is a deformity uniquely seen on autologous radiocephalic AVF. [3][4][5] Its incidence is low and has been reported as 1.7% (14 out of 808 patients). 3 The eighth note may not be seen if there was no collateral branch located at the proximal downstream of the anastomosis or it was ligated at the time of AVF creation surgery.…”

The knowledge, attitudes, and practices of arteriovenous access assessment among hemodialysis nurses: A multicenter cross‐sectional survey

“…Quantitative physical examination indicators, including palpable pulsatility length, the aPump index, and the AVF outflow score, are available arteriovenous accessrelated assessment tools. [26][27][28] These indicators can empower hemodialysis nurses to identify stenosis in the vascular access circuit and also to help them identify patients with stenosis who are at greater risk of thrombosis. Hemodialysis nurses can tailor interventions based on quantitative physical examination indicators, which may improve patient outcomes, enhance nursing quality, reduce health care burden, and increase hemodialysis patients' well-being.…”

Quantitative physical examination indicators to detect patients with stenosis at a high risk of thrombosis at hemodialysis vascular access sites: A retrospective case–control study

“…It had been validated that a short pulsatility length indicated a severe VA inflow stenosis. 8 To better appreciate the severity of stenosis, we measured the pulsatility length starting from the index stenosis instead of the anastomosis as in the original report. The method to measure sPPL was as follows: the pulsatility of an AVF was felt with the finger pad, starting from the index stenosis in the AVF inflow and moving downward along the main trunk of the AVF to where pulsation became imperceptible.…”

“…8,9 The severity of inflow stenosis can be estimated using palpable pulsatility length (PPL), and a PPL of <11 cm, or an access pump index of ⩽1.3, indicates critical inflow stenosis. 8 The severity of outflow stenosis can be categorized by a thrill-and-pulse-based outflow scoring system. The worst score is "PE significant outflow stenosis" (PESOS), which indicates stenosis of ⩾75% in the vascular access (VA) outflow circuit.…”

“…Stenosis-related hemodynamic derangements can be detected by PE, and PE indicators have been reported to quantify stenosis severity. 8,9 The severity of inflow stenosis can be estimated using palpable pulsatility length (PPL), and a PPL of <11 cm, or an access pump index of ⩽1.3, indicates critical inflow stenosis. 8 The severity of outflow stenosis can be categorized by a thrill-and-pulse-based outflow scoring system.…”