768183

review-article2018
JVA0010.1177/1129729818768183The Journal of Vascular AccessAbreo et al.

Review
JVA The Journal of
Vascular Access

The Journal of Vascular Access

Physical examination of the

2019, Vol. 20(1) 7­–11
© The Author(s) 2018
Article reuse guidelines:
hemodialysis arteriovenous fistula sagepub.com/journals-permissions
https://doi.org/10.1177/1129729818768183
DOI: 10.1177/1129729818768183

to detect early dysfunction journals.sagepub.com/home/jva

Kenneth Abreo, Bakhtiar M Amin and Adrian P Abreo

Abstract
The maintenance of vascular access patency for end-stage renal disease patients on hemodialysis is necessary for survival.
Many nephrologists, nurse practitioners, and nurses have limited experience with the physical examination of the
arteriovenous fistula. In this review, we define key terms used in the assessment of an arteriovenous fistula. We discuss
the arteriovenous fistula physical exam, including details of inspection, palpation, and auscultation. Using these concepts,
we review the abnormal findings that can assist practitioners in determining the location of a stenosis. We review the
existing literature that validates physical exam findings with gold standard tests such as ultrasound and angiography.
Finally, we review data supporting the value of training physicians and nurses in arteriovenous fistula physical examination.

Keywords
Physical examination, hemodialysis, arteriovenous fistula

Date received: 24 October 2017; accepted: 6 March 2018

Introduction can be taught to nephrology trainees and nurses.2,4,5 It is

Since the vascular access is the Achilles heel for the hemo-
dialysis (HD) patient, it is vitally important that every
effort should be made to maintain it. All vascular accesses
are subject to the development of stenosis that contributes
to inadequate blood flow and a shortened life span from
thrombosis. KDOQI (Kidney Disease Outcomes Quality
Initiative) vascular access guidelines recommend frequent
monitoring and surveillance of the vascular access.1
Surveillance is defined as the use of instruments to meas-
ure blood flow or intra-access pressures, whereas monitor-
ing is defined as using physical examination (PE) or
clinical indicators to detect vascular access stenosis.2
The purpose of the vascular access examination is to
detect immaturity or dysfunction so that early referral for
correction can be made. Unfortunately, the HD patient’s
caregivers, namely, nephrologists, nurses, and physician
extenders, often do not know how to examine the vascular
access and thereby fail to detect dysfunction early enough
to correct it.3 Delayed diagnosis of dysfunction often leads
to inadequate HD and complications such as hematoma
formation, development of large aneurysms, and thrombo-
sis of the access. PE of the vascular access is a skill that
also possible to teach patients to examine their own vascu-
lar access so that they can become partners in care. The
trained patient would be able to pick up subtle changes in
his or her vascular access and alert the staff to these
changes. Early detection of dysfunction would lead to
timely intervention to correct the problem and prolong the
life of the access.
The vascular access circuit
Only a small portion of the arteriovenous fistula (AVF) cir-
cuit is available for PE (5–10 cm). The vascular access cir-
cuit begins in the left heart carrying blood through the
arteries feeding the AVF and blood is returned through the
draining veins to end up in the right heart. The unseen por-
tion of the vascular circuit can have major implications on
School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
Corresponding author:
Kenneth Abreo, School of Medicine, LSU Health Shreveport, 1501
Kings Highway, Shreveport, LA 71130, USA.
Email: kabreo@lsuhsc.edu
8 The Journal of Vascular Access 20(1)
the function and survival of the access. For example,
severe peripheral artery disease my not allow maturation
of an AVF, whereas central vein stenosis can cause swell-
ing in the access arm due to obstruction of venous flow.
The vascular circuit should be kept in mind during the PE
of the access. PE of the vascular access can be conveni-
ently divided into inspection (look), palpation (feel), and
auscultation (listen). The best time to do a PE is before HD
prior to cannulation of the AVF. Unfortunately, nephrolo-
gists and physician extenders make rounds in HD units
when the patient is receiving HD making PE of the AVF
difficult. HD nurses and technicians are in a unique posi-
tion to do a PE of the AVF before each HD session prior to
needle placement.
PE of the vascular access is an art that is well worth
mastering.6,7 Beathard has made seminal contributions to
the vascular access PE and has divided the PE into three
components: inspection, palpation, and auscultation and
his approach to vascular access examination has been used
throughout the text.7–9
Definitions
It is worth specifying the definitions that will be used
throughout the text so that there will be a uniformity and
clarity of language. In this review, we have confined our
remarks to the examination of AVF as it is the predomi-
nant type of vascular access for HD. The terms proximal
and distal are used in relation to the arm and the terms
inflow and outflow are used in relation to the AVF. Thus,
the inflow portion of the fistula is distal, whereas the
outflow portion of the AVF is proximal. The AVF is arbi-
trarily divided into the inflow, body, and outflow seg-
ments. The inflow consists of a portion of the feeding
artery adjacent to the anastomosis, the artery–vein anas-
tomosis, and the juxta-anastomotic segment (2 cm down-
stream from the arterial anastomosis).1 The body is the
next 5–10 cm (7–12 cm from the arterial anastomosis)
from the inflow segment and is the portion cannulated
for HD. The outflow segment is the remaining portion of
the AVF extending from the body of the AVF to the cen-
tral veins. This segment is usually deep, and lesions here
are located proximal relative to location in the arm.
Aneurysms are significant dilations or bulges in the AVF
at least three times the size of a minimal AVF diameter
of 6 mm (>18 mm).10 They are true aneurysms when the
wall of the aneurysm is the vein wall and pseudo-aneu-
rysms when blood exits from the AVF through a perfora-
tion with soft tissue over the AVF forming the aneurysm
wall. Accessory veins exit the AVF in the inflow or distal
segment of the AVF and are of such caliber (one third to
half the AVF diameter) that they compromise AVF matu-
ration.11 An immature AVF is defined as not reaching
minimal Doppler ultrasound criteria (diameter >5 cm,
Doppler ultrasound blood flow >500 mL/min) or cannot
be used for HD for reasons such as difficult cannulation
or the inability to achieve adequate blood flow.4,12–14
The PE of the vascular access can be divided into three
components: inspection, palpation, and auscultation.
Tables 1 and 2 summarize PE findings and results.
Inspection
The chest and arm on the side of the AVF should be
inspected carefully and compared to the contralateral chest
and arm as a wealth of information can be gleaned from this
examination. Swelling of the AVF arm suggests ipsilateral
subclavian vein stenosis, swelling of the arm and face sug-
gests ipsilateral brachiocephalic (innominate) vein steno-
sis, while swelling of both arms and face suggests superior
vena cava stenosis.15 The presence of supraclavicular and
infraclavicular scars and prominent chest veins suggests
central stenosis from prior tunneled dialysis catheters. The
examiner should then direct attention to the AVF. Long
scars in the forearm or upper arm suggest that the vein used
for access creation was transposed or superficialized. If the
AVF is prominent, the patient should be asked to raise the
arm to see whether the AVF collapses (Arm Raising Test).
If it does collapse, the likelihood of a significant stenosis in
the AVF outflow is remote. Lack of collapse indicates either
an outflow stenosis or a high-flow AVF. Partial collapse of
an AVF suggests a stenosis at the junction of the collapsed
and prominent segments of the AVF. Some AVFs will have
aneurysms in the body of the AVF and most of these are
stable. The occurrence of pain, enlargement, and skin ero-
sion suggest an unstable aneurysm that is likely to rupture
and needs immediate surgical attention.16,17 Finally, atten-
tion should be directed to the ipsilateral hand and fingers.
Constant hand pain and numbness, discoloration and loss
of skin, cyanosis and gangrene of the finger tips, and digital
contractures suggest access-related ischemia.18,19 Paralysis
of the hand often in the distribution of the median nerve
immediately after a new access is placed could result from
ischemia to the nerves of the hand (monomelic neuropathy)
or trauma to the median nerve in case of a forearm AVF.19,20
Palpation
The AVF should be systematically palpated from the arte-
rial to the venous end. A pulsatile AVF suggests a stenosis
in the outflow segment. Pulsatile immature AVFs should
not be cannulated as they form significant hematomas
when the HD needles are removed due to high intra-access
pressure. Either no thrill or a short systolic thrill will be
felt in the pulsatile portion of the AVF, and a continuous
systolic–diastolic thrill will be felt beyond the stenotic
segment.
The quality of inflow into an AVF can be assessed
with the Augmentation Test. Compression of the distal
segment of the AVF 2–3 cm proximal to the arterial
Abreo et al. 9

Table 1.  Key features of the physical examination of the hemodialysis vascular access.

Findings Conclusion
History Difficulty placing needles, low Kt/V, low blood flow Inflow stenosis (JAS, BOF, artery)
Prolonged bleeding after removal of needles, high venous Outflow stenosis
pressure during HD, large aneurysms
Inspection Ipsilateral arm swelling Subclavian vein stenosis
Ipsilateral arm and face swelling Brachiocephalic vein stenosis
Bilateral arm and face swelling Superior vena cava stenosis
Enlarged veins on chest Central vein stenosis
Long scar in forearm or arm Transposed or superficialized AVF
No collapse of AVF with arm raise (Arm Raising Test) Outflow stenosis
Aneurysm with pain, enlargement, skin erosion Impending rupture
Hand cold, hand pain, gangrene of finger tips Steal syndrome
Hand paralysis immediately after access placement Monomelic neuropathy
Palpation Compression of loop AVF Pulsation felt in arterial portion of loop
Pulsatile vascular access with systolic only thrill Outflow stenosis
Compression of access with palpation between arterial Poor augmentation suggests inflow stenosis
anastomosis and occluding finger (Augmentation Test)
Compression of access at 1-cm intervals from arterial to venous Absence of thrill followed by appearance of
end and palpation over access (Sequential Occlusion Test) thrill suggests accessory vein
Auscultation High-pitched predominantly systolic bruit Stenosis

HD: hemodialysis; AVF: arteriovenous fistula; JAS: juxta-anastomotic segment; BOF: body of fistula.

Table 2.  Diagnosis that can be made by a combination of physical findings.

Diagnosis Physical examination findings

Proximal or outflow stenosis
Inflow or distal stenosis
Unstable aneurysm
Central vein stenosis
Accessory vein
Enlarging aneurysms, excessive bleeding from needle sites, low blood flow, poor hemodialysis
adequacy, hyperpulsatile, systolic thrill, arm raising partial or no collapse, normal augmentation,
high-pitched systolic bruit
Immaturity, difficulty sticking, low blood flow, poor hemodialysis adequacy, weak pulse, systolic
thrill, arm raising complete collapse, augmentation poor, high-pitched systolic bruit
Enlargement, pain, thinning of wall, unable to pinch skin, ulceration, inflammation, spontaneous or
excessive bleeding after needle removal
Swelling of ipsilateral arm and face, chest scars and veins, pulsatile AVF, ipsilateral pacemaker
Immature AVF, sequential occlusion test is positive

AVF: arteriovenous fistula.

anastomosis and palpation between the arterial anasto-
mosis and the occluding finger should result in the arte-
rial pulse being transmitted into the AVF resulting in
normal augmentation of the pulse. Poor augmentation in
an immature AVF suggests a juxta-anastomotic or arte-
rial stenosis. The “1-min” AVF exam combines the Arm
Raising Test and Augmentation Test to detect outflow
and inflow stenoses, respectively.
Some immature AVFs have large accessory veins that
emerge from the segment of the AVF close to the arterial
anastomosis and divert blood from the main access chan-
nel. Some of these veins can be easily seen exiting the dis-
tal body of the AVF, whereas in others, especially in the
obese, the veins are deep and cannot be seen. The
Sequential Occlusion Test is done to detect accessory
veins. The AVF is sequentially occluded from the arterial
to the venous end at 1-cm intervals followed by palpation
between the occluding finger and the arterial anastomosis.
The AVF will be pulsatile when the occluding finger is dis-
tal to the accessory vein and no thrill will be felt by the
palpating finger. Once the occluding finger is proximal to
the accessory vein, the palpating finger will feel a thrill
suggesting the presence of an accessory vein.
Auscultation
The normal mature AVF has a continuous bruit that can be
heard in systole and diastole. The bruit is loudest near the
arterial anastomosis. The presence of a stenosis results in a
high-pitched predominantly systolic bruit distal to the ste-
nosis followed by a return of the normal bruit proximal to
the stenosis.
10 The Journal of Vascular Access 20(1)

Table 3.  Confirming physical examination of the hemodialysis vascular access with angiography and ultrasound examination.

Study Design n Physical exam Gold standard Location Sen. (%) Spec. (%) Kappa
Asif et al.22 Prospective, 142 Interventional Angiogram Outflow 92 86 0.78
observational nephrology Inflow 85 71 0.55
Leon and Asif2 Prospective, 45 Nephrology fellow Angiogram Outflow 76 68 0.63
observational Inflow 100 78 0.56
Campos et al.23 Prospective, 84 Nephrologist Ultrasound Overall 96 76 –
observational Doppler Inflow 70 76 0.46
Tessitore et al.24 Prospective, 119 Unknown Angiogram Outflow 75 93 0.63
observational Inflow 98 88 0.84
Coentrão et al.3 Prospective, 177 Nephrology fellow Ultrasound Outflow 97 92 0.92
observational Doppler Inflow – – 0.86
Maldonado- Prospective, 99 Interventional Angiogram Outflow 70 67 0.37
Carceles et al.25 observational radiologist Inflow 82 67 0.50

Confirming the findings of PE with Nephrologists and nurses can be

angiography and ultrasound with
Doppler
To prove that PE of the AVF can detect stenosis, the find-
ings of PE should be validated by gold standard tests such
as angiography and Doppler ultrasound. In 1992, Migliacci
et al.21 showed in 23 patients that the results of PE in detect-
ing stenosis had similar sensitivity (>80%) and positive
predictive value (>80%) as continuous-wave Doppler ultra-
sound. Six prospective observational studies (Table 3) have
compared the detection of stenosis by PE of the AVF to the
gold standard tests, Doppler ultrasound (two studies) and
angiogram (four studies).2,3,22–25 The PE was done by inter-
ventional nephrologists, nephrology fellows, nephrologists,
and interventional radiologists. In one study, we do not
know who did the PE.24 In the majority of studies, the accu-
racy of the PE was compared to the gold standard test using
Cohen’s kappa coefficient in the detection of inflow and
outflow stenoses. A score of 1 indicated complete accuracy,
whereas a score of 0 indicated total inaccuracy of the exam.
The majority of kappa scores were greater than 0.5 for
inflow and outflow stenoses in all studies suggesting that
PE of the AVF is good at detecting stenosis.
Repetitive PE (monitoring) over a defined time span
has not been compared to surveillance in detecting AVF
dysfunction in observational or randomized studies. A
meta-analysis of four randomized controlled studies in
which blood flow measurements done at intervals of
1–3 months were compared to standard care showed that
blood flow measurements were superior.26–30 Blood flow
surveillance significantly decreased the risk of thrombosis
but not the risk of AVF loss. In these studies, standard care
was defined as clinical parameters of AVF dysfunction
such as altered pump pressures or excessive bleeding
from needle sites rather than formal AVF examination.
Based on these studies, perhaps, a monthly PE of AVF
together with other clinical indicators is sufficient to
detect AVF stenosis.
trained to do PE of the AVF
Coentrão et al.3 have shown that the majority of general
nephrologists have inadequate skills in AVF examination. A
total of 177 patients with AVFs were referred by 11 general
nephrologists for evaluation. Their findings on AVF exam of
177 patients were placed in a sealed envelope. A nephrology
resident skilled in PE of AVFs examined the same AVFs and
placed the results in a sealed envelope. The results of the PE
were compared with the gold standard of angiography. The
nephrology resident scored significantly better than the gen-
eral nephrologists (inflow stenosis kappa 0.84 vs 0.49 and
outflow stenosis kappa 0.92 vs 0.58). Leon and Asif 2
showed that following 1 month of training in AVF examina-
tion, a nephrology fellow performed just as well as an inter-
ventional nephrologist. Experienced HD nurses can
diagnose AVF immaturity and dysfunction with PE of the
vascular access, although the length of time spent taking
care of HD patients did not seem to improve these skills.4,5
Conclusion
The PE of the vascular access is convenient, simple, and
economic to monitor dysfunction. The detection of steno-
sis by PE has been validated with diagnostic tests. The
impact of frequent PE on preventing thrombosis and main-
taining AVF patency is not known. Physicians and nurses
caring for the HD patient can be taught PE skills. This skill
can potentially be taught to patients in the hope that they
can detect early dysfunction in the AVF.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Abreo et al. 11
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