Dr. FARSANA.

TK
JUNIOR RESIDENT
Colour Doppler ultrasound in dialysis
access
 DOQI guidelines -creation of a primary AVF is
possible in only 50% of the patient.

 synthetic polytetrafluoroethylene (PTFE)

grafts - predominant form of permanent
vascular acces.
 Angiography - gold standard for imaging of
vascular access abnormalities.

 duplex ultrasound-

 itprovides information both on the morphology

and on the function of vascular access.
 non-invasive bedside procedure with lower costs
and with no need for radio contrast.
PREOPERATIVE VASCULAR EVALUATION
Clinical criteria for the selection of veins and
arteries for the successful placement of an
AVF :-

 visible cephalic vein after tourniquet

placement
 a superficial course of the vein
 absence of tortuous veins
 an easily palpable radial pulse
 a patent palmar arch (Allen’s test)
 absence of significant pressure differences
(20 mmHg) between both arms .
SONOGRAPHIC CRITERIA FOR THE EXAMINATION OF VEINS
BEFORE PLACEMENT OF A VASCULAR ACCESS.

 Using a tourniquet, a venous luminal

diameter of >2.5 mm is required for
placement of an AVF and a diameter of >4.0
mm for grafts.
 absence of segmental stenoses or occluded
segments.
 continuity with the deep venous system in
the ipsilateral upper arm.
without the use of a tourniquet:

 a minimal diameter of the cephalic vein of

>2.0 mm .
ARTERY
 arterial diameter>2.0 mm
 peak systolic velocity of at least 50 cm/s

 significantly increased risk of AVF failure

when the internal diameter of the radial
artery was <1.6 mm.
 Initial diameter and arterial compliance
affect access outcome.
 The distensibility of the arterial wall can be
assessed preoperatively by evaluating the
Doppler waveform in the radial artery during
reactive hyperaemia, induced by reopening a
fist that was clenched for 2 min.
 The high-resistance triphasic wave form
with clenched fist changes to a low-
resistance biphasic waveform after releasing
the fist .

 IMG 1
 resistance index (RI)

peak systolic flow velocity-end diastolic flow

velocity) /peak systolic flow velocity
 A preoperative RI of >0.7 in the feeding
artery after release of the fist indicates that
arterial blood flow will not increase
sufficiently so that the chance of successful
creation of an AVF is reduced.
 TABLE
evaluation of access flow

 diameter of the feeding artery is determined by

B-mode Ultrasonography in a transverse plane
from inner edge to
inner edge.
 The cross-sectional area is calculated by
equipment software.
 At the same site Doppler spectra for calculation
of time averaged velocity (TAV) are obtained in a
longitudinal plane with an insonating angle
maintained at < 60.
 The sample volume size must be sufficiently
large to include the entire luminal cross
 section
 (Figure 2).
 In PTFE grafts, sonographically determined
threshold access flow rates less than 500–800
ml/min are associated with a significantly
increased risk of failure.

 (Table 2) [22,23,25–27].
COLOUR DOPPLER ULTRASOUND CHARACTERISTICS OF
HAEMODYNAMICALLY RELEVANT STENOSES

Direct characteristics at the area of narrowing

 Luminal diameter reduction >50%
 Peak systolic flow velocity >400 cm/s
 Pronounced aliasing phenomenon
 Indirect characteristics at the feeding
brachial artery
 High resistance Doppler waveform
 Reduction in access flow volume
VASCULAR ACCESS STENOSIS

 Graft stenosis usually develop in the venous

outflow tract at the site of anastomosis
between the graft and the vein.

 This is the result of intimal and

fibromuscular hyperplasia, caused by shear
stress.
 The frictional force generated by blood flow
at sites of changing luminal diameter, e.g. at
the site of graft anastomosis, can be
estimated by the aliasing phenomenon seen
in CDU.
 PIC 3
 For calculation of stenosis, the minimal
intraluminal cross-sectional area is compared
with the diameter of a nearby normal
segment usin g the formula
THROMBOSIS AND ANEURYSM FORMATION IN
VASCULAR ACCESS

 Thrombosis- most common cause of vascular

access failure .
 PTFE grafts-thrombosis is primarily the result
of progressive venous outflow stenosis.
 AVFs -occur early because of inadequate flow
resulting from small lumen of vessels or
failure to dilate.
Aneurysms and pseudoaneurysms
 develop at sites of vessel destruction after
repeated cannulation.
 Colour Doppler - ‘to-and-fro’ sign, a typical
waveform characterized by the backflow of
blood from the aneurysmatic sac into the
original vessel lumen during diastole.
 FIG 4
Steal syndrome

 Elderly patients
 Patients with co-morbid conditions
(diabetes, vascular disease) in end-stage
renal disease.
 Because of low resistance in the venous
outflow, the fistula sucks not only the
antegrade flow into the feeding artery but
also ‘steals’retrograde flow from the hand
via the palmar arch and jeopardizes
adequate perfusion of the hand.
STEALSYNDROME –
 when compensatory mechanisms to maintain
peripheral arterial perfusion fail.
Risk factors
 female gender
 age >60 years
 diabetes mellitus

The steal syndrome C/F
 pain at rest
 pain during haemodialysis
 sessions, ulcerations, mostly acral necrosis
and even tissue loss.
 IMG
THANK YOU…..