3. CLINICAL SIGNS OF ACCESS
DYSFUNCTION
• Failure of the fistula to collapse when the arm is elevated.
• Lack of pulse augmentation when the outflow vein is occluded
transiently. This may be more useful in relatively new fistulas
than in older fistulas that are relatively more rigid
• Dialysis events difficult cannulation of fistula, aspiration of
clots, inadequate flows, prolonged bleeding after decannulation.
• Unexplained decrease in KT/V more than 0.2.
5. Is it beneficial?
What is the evidence?
Does it prevent further thrombosis?
What does it do to the fistula longevity?
More Adverse Effects than Benefits?
6. DECREASED THROMBOSIS RATE WITH INCREASED
SURVEILLANCE AND ANGIOPLASTY
Observational, Historical
controls
Besarab, A. et al. Kidney Int. 47:1364-1373, 1995
7. A RANDOMIZED CONTROLLED TRIAL OF BLOOD
FLOW AND STENOSIS SURVEILLANCE OF
HEMODIALYSIS GRAFTS
Ram, S.J. et al. KI 64:272-280; 2003
8. INCREASED SURVEILLANCE AND PREEMPTIVE
ANGIOPLASTY DID NOT PROLONG TIME TO
HEMODIALYSIS GRAFT THROMBOSIS
p=0.12
Ram, S.J. et al. KI 64:272-280; 2003
9. INCREASED SURVEILLANCE AND PREEMPTIVE
ANGIOPLASTY DID NOT PROLONG CUMULATIVE
HEMODIALYSIS GRAFT SURVIVAL
p=NS
Ram, S.J. et al. KI 64:272-280; 2003
10. ULTRASOUND MONITORING TO DETECT
ACCESS STENOSIS IN HEMODIALYSIS
PATIENTS: A SYSTEMATIC REVIEW
Effect on Thrombosis
Tonelli et al. AJKD 51:630-640, 2008
11. ULTRASOUND MONITORING TO DETECT
ACCESS STENOSIS IN HEMODIALYSIS
PATIENTS: A SYSTEMATIC REVIEW
Effect on Access Loss
Tonelli et al. AJKD 51:630-640, 2008
12.
13.
14. A Multi Centre Randomized Controlled Trial of the Clinical and
Cost Effectiveness of Duplex Ultrasound Surveillance With
Proactive Intervention Versus no Surveillance and Reactive
Intervention for the Management of Stenosis in Arterio-venous
Fistulae for Dialysis Vascular Access
Hull UK, completing in 2014
15. Increased Cell Proliferation Activity in the
Restenotic Hemodialysis Vascular Access
After Percutaneous Transluminal Angioplasty
Chang et al. AJKD 43:74-84, 2004.
Conclusion:
“We show markedly high cellular proliferation activity in early restenotic
lesions of arteriovenous fistulae.
These findings indicate that adjunctive antiproliferative therapy is
mandatory in preventing restenosis after PTA, especially in patients
with diabetes.”
16. CONCLUSIONS
Monitoring & prophylactic angioplasty may decrease
fistula thrombosis but not yet shown to prolong access
survival
Data from UIHC did not support monthly flow
monitoring and prophylactic angioplasty for fistulas
17. RECOMMENDATIONS FOR
ACCESS MONITORING
All accesses
Monitor regularly using clinical parameters:
Exam, achievable blood flow rate, dynamic pressures, adequacy of
dialysis
For AV grafts:
Risk of thrombosis is higher
May consider additional monitoring technique:
IAP, flow monitoring or Duplex US
