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Research ArticleClinical Review

Overview of hemodialysis access and assessment

Rohan Arasu, Dev Jegatheesan and Yogeesan Sivakumaran
Canadian Family Physician August 2022; 68 (8) 577-582; DOI: https://doi.org/10.46747/cfp.6808577
Rohan Arasu
Registrar in the Department of Vascular Surgery at Fiona Stanley Hospital and Associate Lecturer in the Faculty of Medicine at the University of Queensland in Brisbane, Australia.
MBBS GDipSurgAnat
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Dev Jegatheesan
Nephrologist in the Department of Nephrology at Princess Alexandra Hospital and Lecturer in the Centre for Kidney Disease Research at the University of Queensland.
MBBS FRACP
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Yogeesan Sivakumaran
Vascular surgeon in the Department of Vascular Surgery at Princess Alexandra Hospital and Senior Lecturer in the School of Clinical Medicine at the University of Queensland.
MBBS FRACS
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    Figure 1.

    Common arteriovenous fistula and arteriovenous graft configurations

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    Table 1.

    Rule of 6s: Sonographic criteria for AVF maturation.

    CRITERIADESCRIPTION
    Outflow vein calibre ≥6 mm on ultrasoundOutflow veins will progressively dilate over time. Generally, a calibre of 6 mm is indicative of an outflow vein that is easy to cannulate and will provide sufficient flow for hemodialysis
    Outflow vein depth <6 mm on ultrasoundIf outflow veins are too deep within the subcutaneous tissues, they may be difficult to cannulate. Those that are too deep may require further surgery for superficialization
    Blood flow >600 mL/minSufficient blood flow is required through the outflow vein to support adequate hemodialysis
    Cannulation >6 wk postcreationIt is often best to wait at least 6 wk postcreation before cannulating an AVF to allow it to arterialize appropriately. This can minimize cannulation-related complications such as hemorrhage or false aneurysms
    • AVF—arteriovenous fistula.

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    Table 2.

    Common autogenous AVF and AVG configurations

    ACCESS TYPEACCESS CONFIGURATIONDESCRIPTION
    Autogenous AVFRadiocephalic (Brescia-Cimino-Appel)An anastomosis is created between the radial artery and the cephalic vein at the wrist. The outflow vein is cannulated in the forearm
    BrachiocephalicAn anastomosis is created between the brachial artery and the cephalic vein at the antecubital fossa. The outflow vein is cannulated in the upper arm
    Brachiobasilic (requiring basilic vein transposition)An anastomosis is created between the brachial artery and basilic vein in the antecubital fossa. This requires a more complex operation as the basilic vein is a deep structure and will need to be mobilized to a more superficial position in the arm to allow it to be cannulated. This procedure can be performed in 1 or 2 stages. The outflow vein is cannulated in the upper arm
    AVGForearm loop graft (brachial artery to median cubital vein or cephalic vein)A prosthetic graft connects the brachial artery and the cephalic vein or median cubital vein within the antecubital fossa. The graft is tunneled as a loop in the proximal forearm
    Upper-arm straight graft (brachial artery to axillary vein)A prosthetic graft connects the brachial artery in the antecubital fossa with the axillary vein in the proximal upper arm. The graft is tunneled as an arc through the upper arm
    • AVF—arteriovenous fistula, AVG—arteriovenous graft.

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    Table 3.

    Strategies for AVF maintenance and preservation of future access sites

    STRATEGYDESCRIPTION
    Consistent assessment for a thrillPatients should be taught to examine for a thrill on a daily basis. If there is loss of thrill or a change in character, they should be advised to present to a vascular access clinic or hospital
    Avoidance of blood pressure assessment on the AVF armPatients should remind health care workers never to take blood pressure readings from the AVF arm as this can compress the outflow vein, potentially causing thrombosis
    Preservation of the AVF outflow veinPatients should remind health care workers to avoid IVC or phlebotomy of the AVF outflow vein
    Preservation of the cephalic and basilic veins of the arm for future access optionsPatients should remind health care workers to avoid IVC of the cephalic, basilic, and antecubital veins to preserve future AVF sites, particularly in the nondominant arm as this is preferentially used for AVF creation. Any essential IVC and phlebotomy should occur in the dorsum of the dominant hand where possible
    Consistent clinical monitoring and surveillance of the AVFMedical practitioners should perform a brief assessment (history and examination) of the AVF on a consistent basis. If any complications are detected on assessment, this should be followed by duplex ultrasonography to assess for arterial inflow or venous outflow lesions that may be amenable to treatment. Alternatively, patients can also be directly referred to a vascular access service
    • AVF—arteriovenous fistula, IVC—intravenous cannulation.

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    Table 4.

    Potential outflow vein complications and associated examination findings

    OUTFLOW VEIN COMPLICATIONEXAMINATION FINDINGS
    Arterial inflow stenosis or nonmaturing outflow veinWill present as a small-calibre outflow vein with a weak or absent thrill
    Venous outflow stenosis (involving either the outflow vein or the central veins)Will present as a hyperpulsatile outflow vein upstream to the obstruction with loss or a change in character of the thrill. Additionally, the outflow vein will be noncollapsing on arm elevation
    Thrombosis of the outflow veinWill present as an indurated, noncompressible, tender outflow vein with no thrill
    Aneurysms or pseudoaneurysms of the outflow veinWill present as focal dilatations of the outflow vein. These dilatations may be associated with cannulation sites but alternatively may be a consequence of venous outflow stenosis
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    Table 5.

    DASS grades of severity

    GRADEDESCRIPTION
    1Cool or pale limb that is asymptomatic
    2Intermittent claudication of the limb during exertion or hemodialysis
    3Rest pain of the limb. Rest pain can often be worst at night and typically improves with dependency
    4Tissue loss of the limb (including ulceration or gangrene)
    • DASS—dialysis access steal syndrome.

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Canadian Family Physician: 68 (8)
Canadian Family Physician
Vol. 68, Issue 8
1 Aug 2022
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Overview of hemodialysis access and assessment
Rohan Arasu, Dev Jegatheesan, Yogeesan Sivakumaran
Canadian Family Physician Aug 2022, 68 (8) 577-582; DOI: 10.46747/cfp.6808577

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Overview of hemodialysis access and assessment
Rohan Arasu, Dev Jegatheesan, Yogeesan Sivakumaran
Canadian Family Physician Aug 2022, 68 (8) 577-582; DOI: 10.46747/cfp.6808577
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