The Addition of Ultrasound Arterial Examination to Upper Extremity Vein Mapping before Hemodialysis Access.

BACKGROUND

Routine upper extremity vein mapping by ultrasound (Ven-US) is recommended by current National Kidney Foundation/Kidney Disease Outcomes Quality Initiative guidelines before arteriovenous fistula (AVF) creation. However, the impact of concomitant arterial US (Art-US) examination is not clear.

METHODS

The Ven-US protocol at our institution was modified to include Art-US starting January 2013. Therefore, retrospective review of patients who received Ven-US with Art-US between January 2013 and July 2014 was performed. The Art-US component included distal brachial and radial artery diameters, level of brachial bifurcation, and Doppler Allen's test. A plan for hemodialysis (HD) access was proposed by 2 attending vascular surgeons (VS1 and VS2) and based on a set of criteria for fistula creation (CFC) using Ven-US findings alone. The Art-US findings were subsequently reviewed, and the plan was changed based on either vascular surgeon judgment (VS1 and VS2) or predetermined arterial anatomic criteria (CFC).

RESULTS

In total, 163 patients (326 arms) were included. The mean age was 53 years, most patients were male (60%), and most were HD dependent at the time of US evaluation (67%). The initial plan based on Ven-US was: 17-19% radiocephalic (RC) AVF, 33-48% brachiocephalic AVF, 20-27% brachiobasilic AVF, and 14-23% grafts. The Art-US revealed 159 radial arteries (49%) with diameter <2 mm, 16 brachial arteries (5%) with high bifurcation, 93 (29%) incomplete palmar arches, and 7 arms (2%) with arterial waveform blunting. Review of Art-US findings resulted in an overall change to the operative plan from 4% to 12% of patients. Those with an initially planned RC AVF were more likely to have a change in operative approach (21-57%) compared with all other types of planned access (1-3%, P < 0.001).

CONCLUSIONS

Preoperative Art-US may significantly change the operative plan, particularly when planning a RC AVF, and should be performed before HD access surgery at the wrist.