Thread by @aishaikh

💥’Physical Examination of the Dialysis Vascular Access’ - Tweetorial

Let’s first review the:
⚡️Anatomy of the Vascular Access
⚡️Vascular Access-related
complications
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@ASDINNews
@RenalFellowNtwk
#VascularAccessPearls

💥 A dialysis vascular access is a ‘circuit’ and NOT just a ‘connection’ between an artery & a vein

⚡️The circuit consists of:
☄️ Pump (heart)
☄️ Inflow (artery)
☄️ Conduit (body of the access)
☄️ Outflow (vein)
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💥 There are 3 basic types of vascular access:
⚡️AVF (arterio-venous fistula)
⚡️AVG (arterio-venous graft)
⚡️CVC (central venous catheter)

☄️AVF: created by a direct connection b/w an artery & a vein
☄️AVG: graft is interposed b/w an artery & a vein👇🏽
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💥 Dialysis Vascular Examination includes:

⚡️Inspection
⚡️Palpation
⚡️Auscultation

☄️Vascular access examination is not only used to detect stenosis, but it is also used to assess several access-related complications
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💥 Inspection

⚡️Assess:
☄️AV access length & diameter
☄️Aneurysm
☄️Infection
☄️Arm swelling
☄️Cyanotic hand, gangrene
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💥 Assess the AV access location, length & depth

⚡️These factors determine if an AV access can be cannulated successfully or not👇🏽
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💥 AV Access Aneurysm

⚡️AVFs can form aneurysms & pseudo-aneurysms👇🏽
⚡️AVGs only form pseudo-aneurysms as they lack the true vascular wall
⚡️A pseudo-aneurysm is essentially a hematoma communicating with the AV access lumen👇🏽
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💥AV Access Aneurysm

⚡️Can be caused by ⬆️ access flow, ⬆️ intra-access pressure (stenosis) or repeated cannulation at the same site

⚡️Hence, it is very important to rotate the cannulation sites!

⚡️Surgical intervention for aneurysm depends on👇🏽
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💥AV Access Infection

⚡️It can be superficial or deep
⚡️Avoid cannulation at or near the infected site
⚡️Superficial Infections can be treated with antibiotics alone, but deep infections require surgical intervention👇🏽
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💥 Arm Swelling

⚡️Indicative of central vein stenosis
⚡️Presence of collateral veins & cardiac devices points toward central vein stenosis👇🏽
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💥 Cyanotic hand, gangrene

⚡️Seen in dialysis access-related steal symdrome (DASS)
⚡️DASS pathogenesis👇🏽
⚡️Indications for surgical intervention for DASS depends on the severity of symptoms & the risk of tissue loss👇🏽

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💥Palpation & Auscultation are used to identify stenosis in the vascular access
⚡️Stenosis can be:
☄️Outflow stenosis: involves the outflow veins
☄️Inflow stenosis: involves the artery or the arterial anastomosis or the juxta-anastomosis👇🏽
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💥 Arm Elevation Test

⚡️Raise the arm above the level of the heart, AVF will collapse if there is no outflow vein stenosis, BUT it won’t collapse if there is outflow stenosis: Video👇🏽

⚡️👆🏽test doesn’t work for AVG due to high level of pressure in AVGs
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💥Palpation

⚡️Assess the ‘Thrill’ (buzz)
⚡️Thrill indicates flow in the AV access, & normally it is soft, continuous during systole & diastole
⚡️In the presence of stenosis, the thrill becomes shortened & disappears during diastole👇🏽

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💥 Palapation

⚡️Assess the pulse over the AV access
⚡️Pulse Augmentation Test: it is used to assess the ‘inflow’ portion of the AV access. See how it’s done in the figure👇🏽

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💥 Palpation

⚡️Feel the pulse over the AV access ⚡️If it is ‘Hyperpulsatile’ then that indicates venous stenosis- figure👇🏽

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💥Palpation

⚡️Sequential Occlusion Test

⚡️Is used to detect side vein branches coming off the AVF
⚡️If there is no side branch then the AVF flow (thrill) disappears when the AVF is occluded, but the thrill persists if a side branch is present: figure👇🏽
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💥 Auscultation
⚡️Bruit is the auditory version of the thrill (Buzz)
⚡️It follows the same pattern as the thrill in the setting of stenosis
⚡️Bruit is continuous & low-pitched, but it becomes localized & high-pitched in the setting of stenosis
Figure👇🏽
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💥Physical Examination of the AV
access is:
⚡️Simple
⚡️Quick
⚡️Inexpensive
⚡️Valuable in detection of stenosis &
other vascular access-related
complications

💥So learn it and do it!

☄️As Yogi Berra famously said..👇🏽

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