CORSO DI ECO COLOR DOPPLER VASCOLARE
SIDV – GIUV - BERTINORO, 3 – 5 APRILE 2008
LA PATOLOGIA VASCOLARE DEGLI ARTI SUPERIORI:
FAV nei soggetti dializzati: valutazione della pervietà e
parametri Doppler.
D. Righi (Firenze)
Carlo Ludovico Bompiani - Bertinoro
GUIDELINE 3
Selection of Permanent Vascular Access and Order of
Preference for Placement of AV Fistulae
A. The order of preference for placement of AV fistulae
in patients with kidney failure who will become hemodialysis
dependent is:
1. A wrist (radial-cephalic) primary AV fistula (Evidence)
2. An elbow (brachial-cephalic) primary AV fistula
(Evidence/Opinion)
B. If it is not possible to establish either of these types
of fistula, access may be established using:
1. An arteriovenous graft of synthetic material (eg, PTFE)
(Evidence) or
2. A transposed brachial basilic vein fistula (Evidence)
C. Cuffed tunneled central venous catheters should be
discouraged as permanent vascular access.
RADIOCEPHALIC FAV
BRACHIOCEPHALIC FAV
Kidney International
(2002) 62, 1109–1124
BRACHIAL
AVF
BRACHIOBASILIC TRANSPOSITION AVF
Clinics vol.60 no.1 São Paulo Jan./Feb. 2005
Assessment of fistula maturation:
In spite of the use of preoperative sonographic
data to select vessels suitable for fistula
construction, some fistulas still fail to mature
adequately for dialysis use.
There may be additional measurements obtained by
preoperative Doppler ultrasound that predict
clinically successful fistulas. These type of
evaluations have not been addressed
systematically, but may include a change in
Doppler flow signal after fist clenching or a
preoperative subclavian venous flow rate>400
mL/min.
Radial-cephalic fistula with
juxta-anastomotic stenosis.
(A) The affected segment
of vein. (B) Postangioplasty
treatment.
Kidney International (2003) 64, 1487–1494
Radial-cephalic fistula with large
accessory vein. (A) Initial
angiogram. A is cannulation site just
above anastomosis. B is cephalic vein
comprising fistula, and C is
accessory vein arising from lateral
aspect of fistula. (B) Angiogram
performed postcoil obliteration.
Arrow indicates location of coil.
Kidney International (2003) 64, 1487–1494
Figure 1: Normal diameter fistula
Copyright ©Radiological Society of North America, 2007Singh, P. et al. Radiology 2007;246:299-305
Figure 2: Accessory vein
Copyright ©Radiological Society of North America, 2007Singh, P. et al. Radiology 2007;246:299-305
Figure 2. Semicoronal images obtained with DSA (A) and three-dimensional contrast-enhanced MR angiography (B) by using a
fast field-echo sequence (4.1/1.34; flip angle, 20{degrees}) show radiocephalic fistula with two stenoses
Copyright ©Radiological Society of North America, 2005 Froger, C. L. et al. Radiology 2005;234:284-291
RadioGraphics, Vol 13, 983-989, 1993
Duplex and color Doppler sonography of hemodialysis arteriovenous
fistulas and grafts
DE Finlay, DG Longley, MC Foshager and JG Letourneau
. Although angiography has been the traditional method of imaging
these vascular systems, duplex and color Doppler sonography offer a
noninvasive method of evaluating dysfunctional hemodialysis access. In
normally functioning fistulas, waveforms of flow in the supply arteries
and throughout the graft are monophasic, with peak systolic velocities
of 100-400 cm/sec and end-diastolic velocities of 60-200 cm/sec. The
draining veins have arterial pulsations with peak velocities of 30-100
cm/sec. Arterial and venous stenoses, graft thrombosis (occlusive and
nonocclusive), infection, aneurysm and pseudoaneurysm formation, and
arterial steal are relatively common abnormalities that can threaten or
destroy graft function and can be diagnosed sonographically. Although
abnormal hemodynamics in access fistulas are usually detected during
hemodialysis, sonographic evaluation at the time of initial dysfunction
may reveal an underlying correctable abnormality, and specific therapy
may be instituted before the condition progresses. In addition, use of
sonography may obviate an invasive angiographic examination if no
significant hemodynamic problem is present.
Radiology 2002;222:103-107
Management of Suspected Hemodialysis Graft Dysfunction: Usefulness
of Diagnostic US.
MC. Dumars, WE. Thompson, EI. Bluth, JS. Lindberg, M Yoselevitz, and Christopher R. B. Merritt, MD
MATERIALS AND METHODS:. Patients were referred by the nephrology
department when clinical findings were suggestive, but not obviously, of graft
malfunction. Study results were deemed normal if flow volume exceeded 1,300
mL/min without significant visualized stenosis of 50% of the diameter or
greater or if flow approached 1,300 mL/min without peak systolic velocity
greater than 400 cm/sec.
RESULTS: Of the 147 examinations, 49 (33%) had normal results, seven (5%)
showed thrombosis at examination, and 91 (62%) had evidence of at least one
significant visualized stenosis or diffuse notable degree of thrombus. Three
patients with normal results required fistulography within 90 days, one for
thrombosis. In the 91 studies with abnormal results, 69 patients underwent
fistulography; results in 63 showed agreement, and three showed false-positive
results. More central venous stenoses were found at fistulography than at US.
CONCLUSION: US is a useful and reliable first step in managing clinically
suspected hemodialysis graft stenosis. One-third of the studies showed no
significant stenosis and did not require angiographic evaluation. US should be
the initial study in patients suspected of having hemodialysis access dysfunction
without exceptional evidence of stenosis
Figure 1b. (a) Power Doppler image of the distal venous limb of the hemodialysis access graft at the
anastomosis with the basilic vein with a normal (4-mm) transverse diameter (crosshairs)
peak systolic velocity of 268 cm/sec, and an average flow greater than 1,300 mL/min.
Copyright ©Radiological Society of North America, 2002 Dumars, M. C. et al. Radiology 2002;222:103-107
The transverse diameter of the focal stenosis was 0.29 cm. Color Doppler flow image at the area
of narrowing of the dialysis graft demonstrates spectral broadening due to turbulent flow and a
peak systolic velocity of 635 cm/sec. This corresponds to an average flow of 429 mL/min.
Copyright ©Radiological Society of North America, 2002 Dumars, M. C. et al. Radiology 2002;222:103-107
DIGITAL
SUBTRACTION
ANGIOGRAPHY
DEMONSTRATES
A COMPLETE
OCCLUSION OF
THE FISTULA
DRAINING VEIN
AT THE
ARTERIOVENOUS
ANASTOMOSIS
(ARROW)
Kidney International (2000) 57, 1169–1175
ANGIOGRAM
AFTER
MECHANICAL
THROMBECTOMY
WITH THE
AMPLATZ DEVICE
AND PTA.
RECANALIZED
FISTULA WITH
EXCELLENT
POSTPROCEDURAL
FLOW (ARROWS)
IS SHOWN.
B-mode image of a thrombosis in the venous outflow tract, showing both fresh (low
echogenicity) and older (high echogenicity) thrombotic material
Copyright restrictions may apply. Wiese, P. et al. Nephrol. Dial. Transplant. 2004 19:1956-1963
Joseph F. Polak, MD, MPH
Director of Cardiovbascular Imaging,
New England Medical Center,
Boston MA
with the assistance of:
Jean M. Alessi-Chinetti, RVT, RDMS
Technical Director
Vascular Diagnostoic laboratory,
Brigham and Women's Hospital,
Boston MA
Figure 1. The Tissue-Engineered Blood Vessel Preoperatively (Panel A), at 3
Months after Implantation (Panel B, Computed Tomographic Angiography), and
at 12 Months after Implantation (Panel C, Doppler Ultrasonography). VA
denotes venous anastomosis, and AA arterial anastomosis.
Nov. 2007