“Descriptive Study of Ultrasound and

Doppler Evaluation of Complications of

Arterio-Venous Access Fistulae”

Dissertation submitted for the degree of M.D. (Radio-

diagnosis) Examination

Maharashtra University of Health Sciences, Nashik

WINTER 2025
 NAME OF COURSE M.D.

SUBJECT RADIO-DIAGNOSIS

ADMISSION YEAR/ACADEMIC 2022

YEAR
 INDEX

Serial Content Page No.

No.

1 INTRODUCTION 5

2 AIMS AND OBJECTIVES 10

3 REVIEW OF LITERATURE 11

4 MATERIALS AND METHODS 43

5 RESULTS 65

6 DISCUSSION 89

7 CONCLUSION 92

8 BIBLIOGRAPHY 93

9 ANNEXURES 116

10 MASTERCHART 127
 INTRODUCTION

Patients with acute renal failure or end stage renal disease require

renal replacement therapy, which includes peritoneal dialysis (PD),

haemodialysis (HD) or kidney transplantation. A vascular access

(VA) is essential for patients on HD and can be accomplished with

central venous catheters (CVC) or with arterialisation of a vein which

can be achieved by connecting the artery with the vein or by

interposition of a graft between an artery and a vein (1)(2).

The first option for the construction of a VA is the creation of an

autogenous AVF (Arterio-Venous Fistula). Secondary and tertiary

options are prosthetic AVG (Arterio-venous Graft) and CVCs. The

reason for creating autogenous AVFs is that observational studies

show a lower incidence of post-operative complications and fewer

endovascular and surgical revisions for AVF failure in comparison to

AVGs. In addition, the use of CVCs results in a significantly higher

morbidity and mortality rate (3)(4).

The etiologies of AV fistula failure are defined in terms of failure of

dialysis through the fistula. Primary failure of AVF is defined as

thrombosis or failure of maturation within 3 months of creation. Early

thrombosis of AVF is defined as an immediate failure due to

thrombosis of the fistula within 24 hours of creation (5). Secondary

fistula failure refers to inadequate hemodialysis flow rates in a

previously dialysed fistula.

Adequate fistula maturation is evaluated by the Rule of 6s; blood flow

of 600 ml/min, diameter of 6 mm in the draining vein and depth of the

draining vein less than 6 mm from the skin surface (6). Fistula

suitability has been defined as the ability to use the fistula for dialysis

with 2 needles and maintain a dialysis machine blood flow rate

adequate for optimal dialysis (≥300 mL/min) during 8 of 12 dialysis

sessions occurring during a 30-day suitability ascertainment period

(7).

The various complications include:

1. Infection of fistula access site

2. Aneurysm/pseudo-aneurysm formation in the draining vein or at

the access site

3. Juxta-anastomotic stenosis/anastomotic breach/venepuncture

segment stenosis

4. Central venous occlusion

 5. Steal syndrome

6. Ischemic neuropathy

7. Fistula rupture

8. Thrombosis (8)(9)(10).

Clinical indicators for inadequacy of fistula function include

abnormal thrill/bruit on palpation, difficulty in cannulation, inability

to achieve target blood flow during dialysis and unexplained decrease

in dialysis dose on a constant dialysis prescription (11).

US (Ultrasound) and doppler is the first-line imaging technique in

diagnosing and working up early (within 3 months) and late (after 3

months) AVFs complications. Although angiography is the gold

standard for vascular access complications, US/PWD (Pulse Wave

Doppler) reliability is very high, using a high-resolution transducer

and high-sensitivity PWD. It provides useful information on the

morphology and the function of vascular access (12).

After successful mapping, a fistula is created and if not functioning

optimally by clinical criteria, the patient is referred for ultrasound and

doppler evaluation of the fistula at the end of 3 months. The first

preference for fistula creation is forearm cephalic vein of non-

dominant hand, forearm cephalic vein of dominant hand, upper arm

cephalic vein, upper arm basilic vein (13).

Ultrasound evaluation of the AV fistula includes greyscale and pulse

wave doppler evaluation of the feeding artery, the anastomotic site,

the draining vein and the rest of the limb vasculature.

The standard protocol for assessment of an AV fistula as elaborated

by Nalesso et al includes the following parameters on B mode and

color doppler evaluation in transverse and longitudinal planes:

1. Identification of the feeder artery, its course; measurement of

diameter, peak velocity and flow rate.

2. Identification of the anastomotic site; measurement of

diameter and peak velocity.

3. Identification of the draining vein, its course; measurement of

diameter, depth from skin, wall characteristics, peak velocity

and flow rate.

4. Identification of any soft tissue or vascular alterations with

adequate measurement and description (14).

Ultrasound evaluation provides vital information used by the

nephrologists to decide the management options. Stenosis of the AV

fistula is usually treated by percutaneous angioplasty (15) while acute

thrombosis is managed by surgical thrombectomy or endovascular

thrombolysis (16).
 RATIONALE OF STUDY

Ultrasound and pulse wave doppler evaluation is considered as the

investigation of choice for assessment of AV fistulae.

 To explore role of greyscale US and pulse wave doppler in

assessment of AV fistula complications.

 Management decisions are made on individual basis with

ultrasound imaging playing a vital role.

AIMS AND OBJECTIVES

Diagnosis of the AV Fistulae complications on ultrasound and

doppler examinations encountered in a tertiary care center.

 REVIEW OF LITERATURE

Chronic Kidney Disease and Renal Replacement Therapy

As per the Kidney Disease: Improving Global Outcomes (KDIGO)

position statement, chronic kidney disease (CKD) is kidney damage

for greater than 3 months as defined by functional or structural

abnormalities of the kidney that can lead to decreased glomerular

filtration rate either in the form of pathologic abnormalities or

markers of kidney damage seen as abnormalities on imaging tests or

abnormalities in urine or blood composition (17). A reduced

glomerular filtration rate is defined as < 60 ml/min/1.73 m^2 for

greater than 3 months. Further, KDIGO classified chronic kidney

disease into 5 stages of severity based on the glomerular filtration rate

as follows (18):
Structural abnormalities as markers for kidney damage detected on

imaging include polycystic kidneys, dysplastic kidneys,

hydronephrosis, cortical scarring, small and hyperechoic kidneys and

renal artery stenosis (19). Pathologic abnormalities on histology

include cystic and congenital diseases, glomerular diseases, vascular

diseases and tubulointerstitial disease (20). Markers of kidney damage

include albuminuria in the form of albumin excretion rate and

albumin: creatinine ratio and abnormal urinary sediments (21).

Renal replacement therapy is the standard of care in patients with end

stage renal disease. Renal replacement therapy is initiated in patients

with an estimated glomerular filtration rate of < 6 ml/min/1.73 m^2 as

per the IDEAL study (22). The Kidney Disease Outcomes Quality

Initiative (KDOQI) suggested that solely estimated glomerular

filtration rate should not be used for decision making about initiation

of renal replacement therapy as it is based on serum creatinine values

which may be affected by creatinine generation from muscle mass.

Instead it suggested an assessment of signs and/or symptoms

associated with uraemia, evidence of protein–energy wasting and the

ability to safely manage metabolic abnormalities and/or volume

overload with medical therapy as guidelines for initiating renal

replacement therapy (23). The options available at present for renal

replacement therapy include pre-emptive transplantation, peritoneal

dialysis, hemodialysis and conservative management.

Peritoneal Dialysis is a technique in which the dialysis occurs for all

24 hours of the day. A permanent catheter is placed in the peritoneal

cavity of the patient and the removal of blood solutes occurs

predominantly by diffusion across the peritoneal lining. The

peritoneal lining has three layers which act as filtration barriers,

including the mesothelium, interstitium and the capillary wall (24).

The osmotic agent used is glucose solution and the chief factor

affecting the efficiency of dialysis is the osmotic gradient along with

the frequency of exchanges and the peritoneal surface area. A number

of studies have been performed which suggest that an approach which

starts with peritoneal dialysis and then switches to hemodialysis is

socially better for patients in terms of Quality Adjusted Life Years

and cost saving (25). The main complications of peritoneal dialysis

are exit site infection and peritonitis which have significant morbidity

and mortality (26).

Renal Transplant is the treatment choice resulting in the best clinical

outcome for patients with end stage renal disease due to advances in

surgical techniques and options for immunosuppression (27). The

options for renal transplant include related living donor, unrelated

living donor and deceased donor; the former of which predominates

in India (28). A retrospective cohort study was conducted in a large

tertiary care Centre in India on 794 patients who underwent renal

transplant over a 10-year period of January 2008–December 2018.

88.9% of recipients had transplants from live donor and 11.1% were

from deceased donor. 97.4% of patients had ABO-compatible

transplant (29). The graft survival at the end of 1 year, 3 years and 5

years was 96.56%, 93.67% and 91.67% respectively. Overall survival

As per KM survival analysis was 81.98%. During the 10-year follow-

up, cumulative graft loss was 9.1%. 43% of the graft loss was

attributed to recipient death with a functioning graft. The second most

common cause of graft loss was rejections. Weight gain till the last

follow-up (from weight at transplant), absence of rejection, recipient

use of ACEI/ARB post-transplant and blood group ‘A’ represented

significant predictors of graft survival (30). Despite renal transplant

being the best management technique in end stage renal disease, it

entails detailed post-transplant care including infection prevention,

immunosuppression, fluid management and monitoring for

complications (31). Another key factor is timely identification of graft

rejection as the transplanted kidney is an antigenically foreign tissue

and activates the immune mechanisms in the recipient. Hyperacute

rejection occurs within minutes to hours after transplantation and is

caused by pre-existing donor-specific antibodies in the recipient that

recognise antigens in the transplanted kidney. Acute rejection can

occur within the 1st week to 3 months after transplantation and occurs

due to cytotoxic T cells that attack the transplanted tissue. Chronic

rejection is an insidious form of rejection that leads to graft

destruction over months or years after transplantation. It is a persistent

allogeneic immune response leading to vascular or parenchymal

damage and, finally, organ fibrosis (32).

However, the most common form of renal replacement therapy in

patients suffering from end stage renal disease worldwide is

hemodialysis ideally performed thrice a week but tailored as per the

nephrologist’s prescription.
Hemodialysis

Dialysis involves the removal of solutes across a semipermeable

membrane by diffusion due to concentration gradient between blood

and dialysate solution and convection wherein there is removal of

small solutes along with water. Water removal occurs by

ultrafiltration due to a pressure gradient between the blood and

dialysate compartment (33). The frequency and duration of dialysis

depend on inter-dialytic weight gains, ultrafiltration rates, blood

pressure control and metabolic control of phosphorous levels, blood

pH and potassium levels (34). The preferred bicarbonate-buffered

dialysate consists of highly purified water with sodium, potassium,

magnesium, calcium, bicarbonate, chloride, and dextrose. It lacks

low-molecular-weight waste products present in uremic blood. When

a semipermeable membrane separates uremic blood and dialysate, the

flux rate of waste solutes from blood to dialysate exceeds the back-

flux from the dialysate to blood. Eventually, the concentrations of

permeable waste products in the dialysate and the blood become equal

with no further net removal of the waste products (35). Hemodialysis

apparatus includes a blood circuit and a dialysis solution circuit

bridged by a dialyser. The dialysate is pumped through the dialysate

compartment, separated from the blood compartment by the dialyzer's

semi-permeable membrane, usually regenerated cellulose. The

temperature and concentration of the dissolved components of the

dialysis solution are regulated. A blood leak detector stops dialysis by

detecting blood products in the outflow dialysate (36). A 15 gauge

needle is inserted into the vascular access. Blood is pumped through

the dialyzer at a rate of 300 to 500 ml/min while dialysate flows in a

counter-current direction at 500 to 800 ml/min. The negative

hydrostatic pressure on the dialysate side is used to achieve adequate

fluid removal or ultrafiltration (37). The prevalent complications

during dialysis include hypotension, hypertension, nausea and

vomiting, fever, muscle cramps, hemolysis and the rare air embolism

(38).

The established options for arterio-venous access for hemodialysis

include arterio-venous grafts, arterio-venous fistula and central

venous catheters.
Arterio-venous Graft

An arterio-venous graft is a prosthetic which is surgically interposed

between the feeding artery and draining vein. It acts as a conduit

between the two vessels which may be some distance apart and allows

punctures for vascular access during hemodialysis (39). The common

materials used as a graft can be biological like human umbilical vein,

cryopreserved saphenous vein, bovine heterografts and denatured

homologous vein allografts. Synthetic graft materials include Dacron

and PTFE, the latter of which is the graft of choice. Synthetic grafts

are preferred due to limited sizes, cost and availability of biological

grafts (40). Arterio-venous grafts are the access of choice in cases of

obese patients with very deep subcutaneous veins, for short term

dialysis in children, patients with fragile veins with hemorrhagic

predisposition like thrombocytopenic purpura and in patients wherein

the artery and vein are a great distance apart (41)(42). Arterio-venous

graft interposition surgery requires thorough pre-operative doppler

evaluation and planning of the limb and a minimal pre-operative

draining vein diameter of 4 mm as established by Silva et al

especially for PTFE anastomosis (43). The most preferred sites for
arterio-venous grafts include forearm grafts in a loop configuration,

forearm grafts in a straight configuration and thigh grafts for fewer

revisions, prolonged patency and lower risk of sepsis (44)(45)(46).

The main drawbacks of arterio-venous grafts is increased

predisposition to infections causing systemic sepsis, propensity for

thrombosis and distal ischemia, all of which are more common with

arterio-venous grafts than with arterio-venous fistulae (47)(48)(49).

Central venous Catheter

Central venous catheters are a universally used access for

hemodialysis. They are used in cases of emergency hemodialysis,

short-term hemodialysis or temporarily during the time of maturation

of the arterio-venous fistulae (50). Central venous catheters don’t

have a maturation time and allow immediate hemodialysis. Central

venous catheters are inserted into the vein using ultrasonography

guidance after careful evaluation of the patency and anatomy of the

vein by the same (51). The preferred site of Central venous catheter

insertion is the internal jugular vein on the right side followed by the

femoral veins and less often the subclavian veins (52). Complications
with central venous catheter insertion include arterial puncture,

pseudoaneurysm formation, accidental arterio-venous fistula

formation, hematomas, pneumothorax when using neck veins, air

embolism and malposition (53)(54)(55). The risk of most of these

insertional complications is significantly reduced when

ultrasonography guidance is used for the procedure (56).

Complications associated indwelling catheters are similar to those of

any hemodialysis access including infection and thrombosis and in

addition, fracture of the catheter or its kinking (57). The type of

central venous catheter inserted depends on the duration of

hemodialysis. If the duration of hemodialysis is less than two weeks,

then an acute non-tunnelled, non-cuffed catheter can be inserted;

however if the estimated duration of hemodialysis is exceeding two

weeks, then a tunnelled, cuffed catheter should be inserted (58). The

difference is that the tunnelled, cuffed catheter is inserted creating a

subcutaneous tunnel within which the cuff leads to fibrosis. This

prevents surface bacteria from entering the bloodstream and is better

for infection prevention in longer terms of hemodialysis.

A study by Drew et al in 2014 regarding choice of vascular access in

incident hemodialysis patients revealed that at least in young patients

under the age of 60 years, the ideal hemodialysis strategy was

initiating hemodialysis via a central venous catheter after attempting

to place an arterio-venous fistula (59). A study comparing utility and

cost of synthetic arterio-venous grafts vs arterio-venous fistulae found

that the latter had significantly better outcomes (60). Arterio-venous

fistulae are hence the first choice vascular access preferred over

arterio-venous grafts owing to higher long term patency due to lesser

thrombosis and infection risks (61). Central venous catheters are least

desirable due to higher risk of morbidity and mortality burden (62)

except in bridging or short term hemodialysis. The during of bridging

hemodialysis could be 10-14 days for arterio-venous grafts as they are

mature at the time of implantation or range from two to twelve

months for arterio-venous fistulae which require time for maturation

(63). Hence an attempt is made to place an arterio-venous fistula at

the time of initiation of hemodialysis through a central venous

catheter.
Arterio-venous Access Fistula

An arterio-venous access fistula is a surgically created

communication between an artery and a vein with an intervening

anastomotic site and a useable segment. The useable segment if the

part of the fistula into which the hemodialysis needles (arterial and

venous) are inserted. It is a part of the draining vein. The useable

segment at the time of initiation of hemodialysis should have the

following characteristics:

- It should be sufficiently long (> 8 cm) to avoid re-circulation

when both needles are inserted into it.

- It should be sufficiently wide and no deeper than 6 mm from the

skin surface to facilitate easy access.

- It should have arterialised, thick walls.

- It should be straight and non-tortuous to avoid counter-

punctures (64).

The site preference for creation of arterio-venous fistulae according to

National Kidney Foundation are distal radio-cephalic in the forearm

followed by proximal brachio-cephalic at the elbow followed by

proximal brachio-basilic in the arm (65). The non-dominant hand is

always preferred over the dominant hand. Different types of

arteriovenous anastomoses are possible: side-to-end of the vein on the

artery, latero-lateral, terminalized side-to-side, side-to-end of the

artery on the vein, and end-to-end. The most common is the

anastomosis of the vein side-to-end of the artery (66). The creation of

a direct communication between a peripheral artery and a peripheral

vein allows the blood to bypass the distal capillary network. This

leads to a significant reduction of peripheral vascular resistance and

blood pressure. The fall in blood pressure augments central

sympathetic outflow and increases the concentration of circulating

angiotensin II, aldosterone, and arginine vasopressin. These

neurohumoral responses increase heart rate, cardiac contractility,

systemic vascular resistance and total blood volume, which together

increase ventricular preload and stroke volume, cardiac output, and

blood pressure (67). Locally, this causes vascular remodelling in the

draining vein leading to increase in the vein diameter and wall

thickness with gradual maturation of the fistula (68). Hence non-

maturation is associated on the contrary with intimal hyperplasia and

insufficient venous expansion.

Duplex ultrasonography in B mode and color doppler is used in pre-

operative assessment of the upper limb vasculature prior to creation of

the Arterio-venous fistula. This allows evaluation of pre-existing

atherosclerotic arterial disease, variations in arterial and venous

anatomy and venous collaterals. B mode is used to evaluate arterial

calibre, uniformity and calcification as these factors impact fistula

maturation (69). Color and spectral dopplers are used to evaluate

arterial phasicity and to rule out proximal and distal arterial disease as

these factors can contribute to post-surgical steal syndrome (70).

Similarly B mode is used to check for diameter of veins and branches

or collaterals along the venous drainage, while color and spectral

dopplers are used to evaluate phasicity for ruling out central venous

occlusion and patency of the superficial veins and detection of small

non-occlusive thrombi (71).

Mature Arterio-venous fistulae have certain vascular changes that can

be detected on ultrasonography and color doppler and serve as criteria

for adequate radiological maturation. A mature Arterio-venous fistula

is defined as a fistula that can be repetitively cannulated over a

continuous 4-week period with two needles for 75% of dialysis

sessions. Ultrasonography criteria for the same vary across the

literature and have been evolving with time. The most widely used

criteria include a minimum draining vein diameter of 4–6 mm and

blood flow rate of 500–600 mL/min or higher with the draining vein

being less than 6 mm deep from the skin surface (72). A recent

prospective study of 227 patients was performed wherein

ultrasonography and color doppler were performed at fortnightly

intervals post fistula creation. It was found that the best timing for

assessment of Arterio-venous fistula maturation was at six weeks post

fistula creation and the best criteria was the Rule of 4 with a

sensitivity of nearly 80% and an accuracy of nearly 85%. This Rule of

4 includes flow volume in the brachial artery greater than 500 ml/min

and vein diameter greater than or equal to 4 mm (73).

B Mode Ultrasonography and Doppler Evaluation

Normal upper limb arteries have no atherosclerotic calcifications,

show uniform color flow and have a triphasic waveform denoting

high resistance as depicted in Image 1 (74).

Image 1: Color and Spectral Doppler of the Brachial and Ulnar

arteries showing continuous color flow with high resistance, triphasic

waveform and velocities around 100 cm/sec suggestive of normal pre-

operative peripheral arterial findings.

Meanwhile, feeding arteries in functioning Arterio-venous fistulae

have high velocity monophasic waveform with loss of resistance and

persistant high velocity end diastolic flow (Image 2)(75).

Image 2: Color and Spectral Doopler of the Brachial artery showing

continuous color flow with low resistance, monophasic waveform

with high diastolic flow and velocities around 70 cm/sec suggestive of

normal mature Arterio-venous fistula feeding artery findings.

Normal upper limb veins are straight, non-tortuous, have low velocity

monophasic flow without significant phasicity. However, post fistula

creation, there is arterialisation of the vein as it receives arterial blood

bypassing the distal high resistance vessels. This causes dilatation and

intimalisation of the draining vein and it develops a pulsatile,

turbulent, high velocity waveform as depicted in Image 3 with some

degree of tortuosity (76).

Image 3: B mode ultrasonography and Spectral Doppler of the

Cephalic vein showing diameter of 8.7 mm, depth from skin of 3.1

mm and a flow volume of 979 ml/min suggestive of normal mature

Arterio-venous fistula draining vein findings.

Post-operative assessment for maturation of the Arterio-venous fistula

or for evaluation of low flow during hemodialysis involves a detailed

B mode ultrasonography and color and spectral dopplers of the upper

limb. The predominant findings noted include vessel wall

characteristics, peak systolic velocity and waveform of the feeding

artery; the peak systolic velocity and diameter of the anastomotic site;

the diameter, intimalisation, depth from skin surface, waveform and

flow volume of the draining vein. Other findings noted include variant
arterial anatomy, color flow and waveform in arteries distal to the

anastomotic site, collaterals or varicosities of the draining vein and

subcutaneous and muscular changes if any (77).

Arterio-venous fistula Complications

Complicated Arterio-venous fistulae can be divided into two types:

Non-maturation of Arterio-venous fistula/Primary Fistula Failure and

Secondary Fistula Failure.

Non-maturation of Arterio-venous fistula/Primary Fistula Failure

occurs when there is inadequate flow during the initial hemodialysis

done at 3 months post-surgical creation or absence of the Rule of 4 or

Rule of 6 features on post-surgical assessment at 3 months. Various

risk factors and causes have been postulated for the same. A

prospective study was conducted with 330 patients having various

arterio-venous fistulae by Pogula et al. It was found that pre-operative

draining vein and feeding artery diameters were significant predictors

of surgical outcome and maturation of the fistulae with cephalic vein

diameter < 2 mm, radial artery diameter < 2.5 mm and brachial artery

diameter < 3 mm being associated with poor outcomes. This conforms

to the generally accepted pre-operative criteria of 2.5 mm as sufficient

cephalic vein diameter (78). Lok et al further established that the

presence of peripheral vascular disease, easily evaluated by pre-

operative ultrasonography is a significant risk factor for failure of

fistula maturation among other clinical factors like the presence of

coronary artery disease and age greater than or equal to 65 years (79).

Early post-operative complications include thrombosis, hematoma

and pseudoaneurysm formation, infection or seroma at anastomotic

site and failure of maturation. Early post-operative thrombosis occurs

due to insufficient vessel diameters causing inadequate flow through

the feeding artery and draining vein, surgical complications,

hypotension and external compression (80). This would appear on

ultrasonography as absent color flow in the thrombosed segment with

proximal high resistance arterial flow, distension of the thrombosed

vessel and eventually with features of non-maturation.

Pseudoaneurysms in the early period often arise at the fistula site due

to weak anastomosis during surgical technique. They appear as

anechoic vascular outpouchings from the fistula site which show yin-

yang pattern on color doppler and to and fro waveform on spectral

doppler as shown in Image 4 (81). When hypoechoic, they must be

differentiated from extra-luminal hematomas by color doppler.

Image 4: Color and Spectral Doppler of the Cephalic vein showing

focal dilatation of the vein with yin-yang pattern of flow on color

doppler and to and fro flow on spectral doppler suggestive of

aneurysm/pseudoaneurysm of the draining vein of Arterio-venous

fistula.
Extrinsic hematomas will appear iso to hypoechoic on B mode

ultrasound depending on the duration since onset. They occur in the

intra or inter-muscular planes due to inadequate hemostasis and may

cause compression of the fistula vasculature leading to easily treatable

stenosis. As mentioned earlier, they should be differentiated from the

much more severe pseudoaneurysms as seen in Image 5 (81).

Image 5: Color and Spectral doppler of the Radial artery showing a

large, extra-luminal, echogenic collection in the subcutaneous plane

causing compression and narrowing the lumen of the underlying

radial artery with resultant aliasing on color doppler and high velocity
flow on spectral doppler suggestive of stenosis due to adjacent

hematoma.

Infection is more common than lymphatic collections or seromas and

is usually diagnosed clinically. Lymphatic collections and seromas

can be detected at the fistula site by ultrasonography and aspirated

under imaging guidance as a diagnostic and therapeutic measure (82).

Late complications of Arterio-venous fistulae occurring after repeated

cannulation of the fistula for hemodialysis include stenosis which may

be at the anastomotic site, juxta-anastomotic region or in the draining

vein, thrombosis of the vessels, aneurysmal dilatation of the draining

vein, steal phenomenon, cephalic arch stenosis and rupture causing

torrential hemorrhage.

The most common overall complication of Arterio-venous fistulae is

stenosis. According to the 2019 ACR-AIUM-SRU recommendations,

ratio of PSV of anastomotic site and artery 2 cm upstream being > 3:1

is indicative of > 50% anastomotic site stenosis, ratio of PSV of

narrowed draining vein and vein 2 cm caudal being > 2:1 is indicative

of > 50% venous end stenosis and a PSV > 375 cm/sec at anastomotic

site or in the draining vein may be indicative of > 50% stenosis (83).
Juxta-anastomotic stenosis is an inflow type of stenosis occurring

most often in radio-cephalic fistulae while cephalic arch stenosis is an

outflow type of stenosis occurring most often in brachio-cephalic

fistulae (84). Stenosis of the draining vein appears on B mode as

visible narrowing of the vein calibre for a short or long segment with

irregular echogenic wall thickening. Color and spectral doppler show

aliasing and turbulent high velocity flow as seen in Image 6 (81).

Image 6: B mode ultrasonography, Color and Spectral doppler of the

Cephalic vein showing long segment luminal narrowing on B mode,

aliasing on color doppler and high velocity up to 500 cm/sec on

spectral doppler suggestive of long segment draining vein stenosis.

Outflow type cephalic arch stenosis occurs due to dynamic

compression of the clavipectoral fascia on the piercing cephalic vein

during shoulder movements in high flow brachio-cephalic fistulae. It

is seen on color doppler as focal short segment of aliasing and high

velocity. It can be further evaluated by an upper limb contrast CT

angiography or a digital subtraction angiography of the fistula as seen

in Image 7 (85).

Image 7: Digital Subtraction Angiography of the left Arterio-venous

fistula showing significant luminal narrowing at the cephalic arch

suggestive of stenosis which increases in diameter significantly

following balloon angioplasty.

Arterio-venous fistula thrombosis usually occurs in the presence of

underlying stenosis which reduces the blood flow due to high

resistance. It may also be attributed at times to hypoperfusion or

hypotension (86). A large proportion of Arterio-venous fistula

thrombosis cases lead to access abandonment (87). On

ultrasonography, thrombosis is seen as short or long segment

echogenic content within the vessel with absence of color flow and

spectral waveform on doppler. In addition, the proximal arterial

segment will lose its low resistance monophasic waveform which is

seen in feeding arteries and will develop a high resistance triphasic

waveform with reduced PSV as is shown in the Image 8 (81).

Image 8: Color and Spectral doppler of the Brachial artery showing

high resistance triphasic flow in the feeding artery of an Arterio-

venous fistula suggestive of distal occlusion. B mode ultrasonography

of the Cephalic vein showing echogenic intra-luminal content

occupying the entire diemeter with expansion of the vein suggestive

of long segment acute to subacute draining vein thrombosis.

Aneurysms and pseudoaneurysms occur in the draining vein due to

repeated cannulation and high flow rates causing shear forces on the

internal elastic lamina. Another contributory factor is the presence of

antegrade stenosis in the draining vein which increase the local

venous pressure (88)(89).

Steal syndrome refers to flow reversal in the artery distal to the fistula

site. It requires both symptoms in the distal fistula lib as well as

arterial blood flow reversal into the draining vein via the fistula site.

Symptoms can include paraesthesias, ischemic pain, cool and clammy

upper limb and in severe cases tissue necrosis. However, clinically

symptomatic Steal syndrome is rare because of abundance of

collaterals providing distal arterial flow and reduced limb vascular

resistance (90). Predisposing factors include proximal access fistulae

(brachio-cephalic), prior instrumentation of the limb, diabetes and

atherosclerosis. On color doppler, Steal syndrome manifests as

retrograde flow in the artery distal to the fistula site as shown in

Image 9 (81) and a change to antegrade, high resistance flow when

there is manual compression of the draining vein.

Image 9: Color and Spectral doppler of the Brachial artery proximal

to the fistula site showing antegrade flow and Brachial artery distal to

the fistula site showing retrograde flow suggestive of Steal

phenomenon.

Another less common, non-obstructive complication of Arterio-

venous fistulae is cardiac failure. It usually occurs in high flow

fistulae. A high flow fistula is defined as one with a flow volume >

2000 ml/min. It occurs most commonly in proximal brachial artery

fistulae especially with anastomosis diameter > 4-6 mm (91). It is a

common indication for surgical closure of the Arterio-venous fistula

to prevent worsening of cardiac failure.

CT angiography of the access fistula is a non-invasive, informative

investigation. It allows evaluation of soft tissue, central vasculature

which is minimally seen on ultrasonography and better interpretation

of vascular morphology using Volume-Rendered images and

Maximum-Intensity-Projections (92). CT angiography is also useful

for detection of subclavian occlusion (93) and central venous

occlusion that occurs due to repeated neck vein or proximal upper

limb vein cannulation in patients with chronic kidney disease.

Management

Stenosis is the most common cause of hemodialysis access Arterio-

venous fistula failure. The landmark treatment for the same is

percutaneous transluminal balloon angioplasty. This is performed

under guidance of digital subtraction angiography and

ultrasonography for peripheral veins. It involves the use of non-

compliant, high-pressure balloons which are inflated across the site of

stenosis to dilate the arterialised draining veins. The critical decision

is regarding the size and type of balloon required which is made based

on the digital subtraction angiography findings (94). Further, re-

stenosis can be prevented in resource rich settings by Drug Coated

Balloons which use chemotherapeutic agents like Paclitaxel to induce

apoptosis of the regenerative cells accumulating after angioplasty to

maintain patency of the vessel (95).

Acute thrombosis of an Arterio-venous fistula is treated with

pharmaco-mechanical endovascular thrombectomy along with

percutaneous angioplasty for any underlying stenosis (96).

Chronically thrombosed draining veins lead to stenosis and

development of numerous collaterals. Hence such Arterio-venous

fistulae are usually abandoned due to poor primary patency rates

following endovascular treatment.

High output cardiac failure as described earlier is usually treatable by

surgical closure of the Arterio-venous fistula with resolution of

symptoms. An alternative management is banding of the Arterio-

venous fistula. Aneurysms and pseudoaneurysms require surgical

management if there is atrophy of the overlying skin, spontaneous

hemorrhage, rapid increase in the size of the aneurysm or tortuosity

limiting the possibility of cannulation and stenting (97). Temporary

stent graft placement can be considered if the patient is at high risk of

rupture and hemorrhage; however owing to infection rates and access

difficulties, surgical management is recommended. Asymptomatic

patients with radiologically detected Steal syndrome do not require

management. Mild symptoms are treated conservatively with hand

exercises and hand warming methods (98). Severe symptoms with

distal ischemia warrant endovascular management which includes

percutaneous angioplasty for arterial stenosis and ligation and

banding of collaterals and high flow Arterio-venous fistula

respectively in extreme cases (99). The main aim of management of

complications is to try to salvage the Arterio-venous fistula for as

long as possible in order to obviate the need for creation of a new

access.

Prior to B mode ultrasonography and doppler studies however, a

radiologist must clinically evaluate the Arterio-venous fistula which

could provide an aid towards the diagnosis. This includes inspection

for aneurysms and vessel collapse on overhead abduction of the arm;

auscultation for a low pitch, continuous systolic and diastolic hum;

palpation for thrill throughout the anatomical Arterio-venous fistula

which is compressible (100). Any alterations in this physiology can

indicate complications which can be corroborated with imaging

findings.
 MATERIALS AND METHODS

Study Design: Cross-sectional prospective observation study.

Study Area: Medical College and tertiary care hospital in a

metropolitan city.

Study Period: 12 months.

Study Instrument: USG: WIPRO GE LOGIQ P9

Sample size: Type of Study: Descriptive Study

Objective: Diagnosis and description of US/PWD findings in patients

with AV Fistula complications in a tertiary care center.

Sample Size Calculation:

Given:

- Population proportion (p): 19.10%

- Margin of error (E): 12%

- Confidence level: 95%

Formula:

n = (Z^2 * p * (1 - p)) / E^2

Calculation:

p = 0.191

E = 0.12

Z ≈ 1.96 (for 95% confidence level)

n = (1.96^2 * 0.191 * (1 - 0.191)) / 0.12^2

n ≈ (3.8416 * 0.191 * 0.809) / 0.0144

n ≈ 0.599938432 / 0.0144

n ≈ 41.66317953

Sample size (rounded up): 42

The minimum calculated sample size is 42.

Inclusion criteria:

All patients referred for ultrasound evaluation for inadequately-

functioning fistulae or fistula complications as per clinical criteria.

Exclusion criteria:

- All patients who do not consent to be a part of the study.

- Patients with AV fistulae deemed adequate for dialysis by

clinical criteria and without complications.

Ethics:

- Proper informed consent was be taken from the patients after

explaining them about risks and benefits of examination.

Patients were not required to undergo additional diagnostic

procedures, incur additional expenditure or be exposed to

radiation for the purpose of the study.

Study Procedure:

- Essential clinical history was obtained and all the study related

data was collected prior to the ultrasound. Particular details

included history of fistula creation, history of dialysis using

concerned fistula and history of current fistula status. Patients

did not have inconvenience of performing additional

visits solely for the purpose of the study. Patients were scanned

on WIPRO GE LOGIQ P9 sonography machine.

 - After explaining the procedure to the patients, the ultrasound

was done. The patients were asked to lie supine with the fistula

arm extended alongside the body. Using the linear array

transducer (3-12MHz) the feeding artery, anastomosis site,

draining vein and rest of the vasculature of the concerned arm

were evaluated.

- Initial greyscale evaluation was followed by pulse wave doppler

evaluation to establish diameter of vessels, wall status, lumen

status and flow volumes among other parameters.

Technique:

Patients were examined in supine position with the fistula arm by the

side in supination and 20-30 degrees of abduction. Patients were

asked to keep the upper limb bare from the scapula to the fingers. The

fistulae were palpated for presence or absence of thrill and inspected

for color change in the skin, aneurysmal dilatations of the veins and

cold, clammy palms. A high frequency linear transducer was used to

assess the arterial and venous vasculature from the subclavian vessels

till the palmar arch. Note was made for anatomical variants in arterial
circulation like a high-branching axillary artery or venous circulation

like anomalous collaterals or communications with deep veins.

First the arterial system was evaluated on B mode ultrasonography for

vessel diameters, wall calcifications or intimal thickening and

tortuosity. Then the arterial system was evaluated on color doppler for

continuous antegrade color flow in the arteries proximal as well as

distal to the fistula site. Lastly the arterial system was evaluated on

spectral doppler for peak systolic velocity and waveform pattern with

expectant finding being low resistance monophasic waveform

proximal to the fistula site and high resistance triphasic waveform

distal to the fistula site.

Second the venous system was evaluated on B mode ultrasonography

for vessel diameters, depth from the skin surface, presence of

collaterals and aneurysms and tortuosity. Then the venous system was

evaluated on color doppler for continuous color flow. Lastly the

venous system was evaluated on spectral doppler for peak systolic

velocity and flow volume.

Third, the fistula site was evaluated for peak systolic velocity and

diameter.
The ideal site for peak systolic velocity in the artery was deemed to be

2 cm proximal to fistula site. The ideal site for peak systolic velocity

and flow volume in the vein was deemed to be 10 cm proximal to

fistula site. Both were in keeping with current literature.

Stenosis

Stenosis was found at the anastomotic site, in the juxta-anastomotic

vein, in the draining vein and at the cephalic arch. It was found to be

long segment, short segment, unifocal or multifocal.

Image 10: Color and Spectral Doppler of the Cephalic vein showing

aliasing with luminal narrowing in the Cephalic vein for a short

segment with PSV ~ 765 cm/sec suggestive of significant venous

stenosis.

Image 11: Color and Spectral Doppler of the anastomotic site

showing aliasing with maintained lumen and PSV ~ 553 cm/sec in the

presence of feeding artery PSV ~ 40 cm/sec suggestive of significant

anastomotic site stenosis.

Image 12: Color and Spectral Doppler of the juxta-anastomotic

cephalic vein showing aliasing with narrowed lumen and PSV ~ 210

cm/sec in the presence of feeding artery PSV ~ 60 cm/sec suggestive

of significant juxta-anastomotic venous stenosis.

Image 13: Color and Spectral Doppler of the cephalic vein where it

pierces the clavipectoral fascia showing aliasing with narrowed lumen

and PSV ~ 560 cm/sec suggestive of significant cephalic arch venous

stenosis.

Thrombosis

Thrombosis was found in the draining cephalic vein, fistula site and

the feeding artery. It was found to be long segment, short segment,

unifocal or multifocal. It was associated with luminal narrowing of

the vein and arterial triphasic high resistance flow.

Image 14: B mode ultrasonography of the radio-cephalic Arterio-

venous fistula showing long segment echogenic thrombosis of the

juxta-anastomotic cephalic vein extending proximally into the

proximal vein.

Image 15: Color and Spectral Doppler of the fistula site showing

short segment echogenic thrombus just distal to the anastomosis with

proximal high resistance arterial triphasic waveform. The patient had

a 2 mm cephalic vein suggestive of non-maturation due to juxta-

anastomotic thrombosis.
Image 16: B mode ultrasonography of the cephalic vein at the elbow

showing long segment echogenic thrombosis of the cephalic vein

which was accompanied by change of feeding arterial waveform to

high resistance and low velocity.

Aneurysms

Focal dilatation of the draining vein were seen in the form of ectatic

varices usually at the cannulation site with or without partial lumen

occluding thrombosis and overlying skin changes. Aneurysms were

also seen in the feeding radial and brachial arteries.

Image 17: B mode ultrasonography of the fistula site showing a large,

anechoic dilated vascular channel communicating with the superficial

cephalic vein and appearing to communicate with the deep radial

artery suggestive of juxta-anastomotic aneurysmal blow-out.

Image 18a: B mode ultrasonography of the draining cephalic vein

showing long segment aneurysmal dilatation of the draining vein with

partial lumen occluding eccentric thrombus.

Image 18b: Color doppler of the draining cephalic vein in the same

patient showing aneurysmal dilatation of the draining vein with partial

lumen occluding eccentric thrombus and yin yang pattern of color

flow in the patent lumen of the aneurysm.

Image 19: B mode ultrasonography of the feeding Brachial artery

showing short segment aneurysmal dilatation of the brachial artery

with partial lumen occluding eccentric thrombus.

Extra-vascular Collections

Extra-vascular collections were seen in the form of hematomas and

seromas in the subcutaneous or muscular planes with or without

compression of the adjacent fistula vessels.

Image 20: B mode ultrasonography at the fistula site in a patient 2

weeks post-surgical creation of fistula showing an anechoic, well-

defined collection in the subcutaneous plane just superficial to the

fistula. It showed no color flow on color doppler suggestive of post-

operative seroma.
Image 21: B mode ultrasonography of the cephalic vein in a patient

with recent hemorrhage from cannulation site and local swelling

showing a hypoechoic, ill-defined collection in the subcutaneous

plane just superficial to the cephalic vein and sharing a wall with it. It

showed no color flow on color doppler suggestive of cephalic vein

rupture with superficial hematoma.

Steal Phenomenon

Steal phenomenon was seen in the form of retrograde flow in the

artery distal to the fistula site with flow through the dilated palmar

arch.
Image 22: Color and spectral doppler of the radial artery at wrist

distal to the fistula site showing retrograde flow suggestive of Steal

phenomenon in a patient with palm swelling.

Image 23: Color and spectral doppler of the radial artery at wrist

distal to the fistula site showing retrograde flow with biphasic

velocity suggestive of Steal phenomenon in a patient with arm

swelling.

Image 24: Color and spectral doppler of the ulnar artery at wrist

showing antegrade monophasic flow with atherosclerotic wall

calcifications in a patient with retrograde flow in radial artery distal to

fistula site suggestive of Steal phenomenon with significant

atherocalcific changes.

High Flow Fistula

High flow was seen as flow volume > 2000 ml/min with numerous

collaterals in proximal brachial artery-based fistulae.

Image 24: B mode and spectral doppler of the cephalic vein in the

proximal arm in a patient with brachio-cephalic fistula at elbow

showing flow volume ~ 6760 ml/min suggestive of high flow in a

patient with arm swelling and numerous collaterals.

Image 25a: Digital Subtraction Angiography showing long segment

juxta-anastomotic venous segment irregular luminal narrowing with

tortuosity of the feeding artery suggestive of significant stenosis.

Image 25b: Digital Subtraction Angiography showing inflated

balloon at the aforementioned stenotic site during angioplasty.

Image 25c: Digital Subtraction Angiography showing significant

increase in juxta-anastomotic venous segment calibre post successful

angioplasty.
Image 26: Digital Subtraction Angiography showing multifocal short

segment juxta-anastomotic and middle venous segment luminal

narrowing with intermittent dilatation suggestive of stenosis.

Image 27: Digital Subtraction Angiography via a venous end

puncture showing short segment venous luminal narrowing with

intermittent dilatation suggestive of significant stenosis.

Image 28: Digital Subtraction Angiography via a venous end

puncture showing short segment severe luminal narrowing in the

subclavian vein with severe dilatation of the draining axillary vein in

a patient with a high flow brachio-basilic fistula and arm swelling

suggestive of severe stenosis.

Data Analysis:
All the data was in a case record form, elaboration of the ultrasound

findings was done and statistical evaluation of prevalence of

individual complications in our tertiary care center was done.

The data was collected and compiled using Microsoft Excel [2007

Version]. The qualitative variables were expressed in terms of

percentages. The quantitative variables were both categorized and

expressed in terms of percentages or in terms of mean and standard

deviations.
 RESULTS

Patient distribution according to gender

In the present study of 44 patients, 15 were women (34.1%) while 29

were men (65.9%) (Table 1, Graph 1).

NUMBER PERCENTAGE

WOMEN 15 34.1%

MEN 29 65.9%

TOTAL 44 100%

Table 1 : Patient distribution according to gender

Gender Distribution

Women Men

Graph 1 : Patient distribution according to gender

Patient distribution according to age

The study population was divided according to their age groups as

follows: 0-10 years, 11-20 years, 21-30 years, 31-40 years, 41-50

years, 51-60 years and 61-70 years (Table 2, Graph 2).

Age in Years Number of Patients Percentage

0-10 0 0

11-20 5 11.3%

21-30 4 9.1%

31-40 6 13.6%

41-50 13 29.5%

51-60 10 22.7%

61-70 6 13.6%

Total 44 100%

Table 2 : Patient distribution according to age

 Age
35%

30%

25%

20%

15%

10%

5%

0%
0-10 yrs 11-20 yrs 21-30 yrs 31-40 yrs 41-50 yrs 51-60 yrs 61-70 yrs

Age

Graph 2 : Patient distribution according to age

The majority of the patients presenting with complicated fistulae

belonged to the age group 41-50 years (29.5%) followed by 51-60

years (22.7%). Relatively fewer patients belonged to the younger age

groups of 11-20 years (11.3%) and 21-30 years (9.1%). There were no

patients below the age of 10 years.

The reason for the prevalence of complicated fistulae in the older age

group may be attributed to the higher prevalence of chronic kidney

disease and hence AV access fistulae in the older populations than in

younger populations.
This may in turn be attributed to the higher prevalence of acquired

causes of chronic kidney disease than congenital causes necessitating

renal replacement therapy in the sample population.

Patient distribution according to time since creation of fistula

As per International consensus, fistula maturation is ideally assessed

by ultrasonography and doppler studies at 3 months post surgical

creation of the fistula. Alternatively, in resource constraint settings,

the first dialysis is attempted without radiologically confirming

maturation at 3 months since fistula creation. Inadequately

functioning fistulae at less than or equal to 3 months since creation

are termed to have undergone “Primary fistula failure”. On the other

hand, fistulae functioning adequately at 3 months since creation and

showing inadequate flow anytime after that are termed to have

undergone “Secondary fistula failure”.

Of our 44 patients, 13 patients (29.5%) were referred at or before 3

months since fistula creation while the remaining 31 patients (70.5%)

were referred at any time greater than 3 months since fistula creation

up to 20 years.
 NUMBER PERCENTAGE

AT/BEFORE 3 MONTHS 13 29.5%

AFTER 3 MONTHS 31 70.5%

TOTAL 44 100%

Table 3 : Patient distribution according to time since creation of

fistula

Time since creation of fistula

</= 3 months > 3 months

Graph 3 : Patient distribution according to time since creation of

fistula

The Nephrology department at our institute followed the International

consensus regarding timing for referral of patients for

ultrasonography and doppler studies.

Patient distribution according to side of fistula

Majority of the patients had their fistula in the left upper limb (75%)

while the remaining had their fistula in the right upper limb (25%). Of

the 8 patients with the fistula in the right upper limb, 3 patients were

left-handed in activities of daily living, while the remaining 5 patients

were right-handed but had prior failed fistulae in the left upper limb.

On the contrary, of the 36 patients with the fistula in the left upper

limb, 31 patients were right-handed in activities of daily living, while

the remaining 5 patients were left-handed but had prior failed fistulae

in the right upper limb.

NUMBER PERCENTAGE

RIGHT UPPER LIMB 8 25%

LEFT UPPER LIMB 36 75%

TOTAL 44 100%

Table 4 : Patient distribution according to side of fistula

 Side of Fistula

Left Right

Graph 4 : Patient distribution according to side of fistula

The preferential creation of the fistula in the non-dominant upper limb

as observed in this study is in keeping with fistula creation guidelines

and limb preference orders.

Patient distribution according to site of fistula (Feeding Artery)

As aforementioned, the preferential site of fistula creation is a radio-

cephalic fistula in the non-dominant hand. This is followed by radio-

cephalic fistula in the dominant hand. Brachial artery fistulae are

generally created in 2 situations; the first being unfavorable venous

anatomy of the cephalic vein in the forearm or wrist; the second being
a failed radio-cephalic fistula. Of our 44 patients, 27 patients (61.3%)

had a radio-cephalic fistula generally at the wrist while the remaining

17 patients (38.7%) had a brachio-cephalic or brachio-basilic fistula at

the cubital fossa.

NUMBER PERCENTAGE

Radial Artery Fistula 27 61.3%

Brachial Artery Fistula 17 38.7%

TOTAL 44 100%

Table 5 : Patient distribution according to site of fistula (Feeding

Artery)

Site of Fistula (Feeding Artery)

Radial Artery Fistula Brachial Artery Fistula

Graph 5 : Patient distribution according to site of fistula (Feeding

Artery)
Patient distribution according to Presenting Complaint

Of our 44 patients, majority of the patients presented with Low

Fistula Flow during dialysis (77.2%) while very few patients

presented with Palm Swelling, entire Arm Swelling or Local Swelling

in isolation or in addition to Low Fistula Flow.

NUMBER

Low Fistula Flow 34

Palm Swelling 3

Arm Swelling 4

Local Swelling 5

TOTAL 44

Table 6 : Patient distribution according to Presenting Complaint

Presenting Complaint
40

35

30

25

20

15

10

0
Low Fistula Flow Palm Swelling Arm Swelling Local Swelling

Presenting Complaint
Graph 6 : Patient distribution according to Presenting Complaint

The chief presenting complaint for ultrasonography and doppler

evaluation of AV access fistulae in this study was low/inadequate

flow through the fistula during dialysis. In the interim of analysis and

treatment of the fistula, the Nephrologists would continue the dialysis

via a central venous catheter or have a Tunnelled Cuff Catheter

inserted by Interventional Radiology.

Patient classification based on Fistula Flow Volume

Of the 44 patients in the study, majority of the patients had inadequate

flow volumes on doppler assessment (< 500-600 ml/min) in the

draining vein (72.7%) while few patients had adequate flow volumes

in the presence of other complications (18.2%) and only 4 patients

had high flow fistulae (> 1000 ml/min) in the draining vein (9.1%).

NUMBER PERCENTAGE

Inadequate Fistula Flow 32 72.7%

Adequate Fistula Flow 8 18.2%

High Flow 4 9.1%

TOTAL 44 100%

Table 7 : Patient classification based on fistula flow volume

 Fistula Flow Volume
80.00%

70.00%

60.00%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00%
Inadequate Fistula Flow Adequate Fistula Flow High Flow

Fistula Flow Volume

Graph 7 : Patient classification based on fistula flow volume

In the study population, there were a total of 4 patients with High

Flow fistulae on doppler analysis. These patients had draining vein

flow volume in excess of 2000 ml/min. All 4 of these patients had

Brachial artery-based fistulae at the elbow. However, of 17 patients

with Brachial artery-based fistulae, only 4 had High fistula flow.

Patients with inadequate fistula flow were then segregated based on

the duration since fistula creation when they presented. As mentioned

above, patients presenting at or before 3 months with inadequately

functioning fistulae were deemed to have Primary Fistula

Failure/Non-maturation of fistula whereas those presenting after this

time frame with inadequately functioning fistulae were deemed to

have Secondary Fistula Failure.

Consequently, it was observed that of the 32 patients with inadequate

fistula flow volumes, the majority had secondary fistula failure

(62.5%), while the remaining had primary fistula failure (37.5%).

NUMBER PERCENTAGE

Secondary Fistula Failure 20 62.5%

Primary Fistula Failure 12 37.5%

TOTAL 32 100%

Table 8 : Classification of patients with Inadequate Fistula Flow

Volumes

Inadequate Flow Volume

Secondary Fistula Failure Primary Fistula Failure

Graph 8 : Classification of patients with Inadequate Fistula Flow

Volumes

Identification of Causes of Primary Fistula Failure

Primary Fistula Failure/Non-Maturation of Fistula was seen in

patients with inadequate flow volumes in the draining vein at or

before 3 months from fistula creation. The most common causes for

primary fistula failure were found to be Juxta-anastomotic venous

stenosis/thrombosis (41.6%) and anastomotic site stenosis (33.4%).

Other less common causes included numerous venous collaterals

(16.7%) and arterial anomalies (8.3%).

NUMBER PERCENTAGE

Anastomotic site stenosis 4 33.4%

Juxta-Anastomotic Venous 5 41.6%

stenosis/thrombosis

Numerous collaterals 2 16.7%

Arterial anomaly 1 8.3%

TOTAL 12 100%
Table 9 : Causes of Primary Fistula Failure

Causes of Primary Fistula Failure

45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Anastomotic site stenosis Juxta-anastomotic vein Numerous collaterals Arterial anomaly
stenosis/thrombosis

Causes of Primary Fistula Failure

Graph 9 : Causes of Primary Fistula Failure

The above table shows that the anastomotic site and juxta-anastomotic

vein were commonly involved in fistula failure by

stenosis/thrombosis. This can be attributed to surgical complications

as these patients were dialysis naïve and the complication occurred in

close proximity to the surgical site. On the other hand, both the

patients with non-maturation of fistula due to numerous collaterals of

the draining vein gave history of fistula creation without prior

ultrasonographic and doppler mapping of the vasculature of the limb.

It is postulated that the presence of numerous collaterals drains off the

fistula blood and does not allow adequate arterialisation of the

draining vein leading to inadequate flow volume/depth/diameter of

the vein. 1 patient had an aneurysmal dilatation of the feeding artery

leading to altered hemodynamics of the flow into the fistula and

causing non-maturation.

Identification of Causes of Secondary Fistula Failure

Secondary Fistula Failure was seen in patients with inadequate flow

volumes in the draining vein at any time after 3 months from fistula

creation. The most common cause for secondary fistula failure was

found to be draining vein thrombosis (55%) which included acute and

subacute thromboses followed by critical draining vein stenosis (35%)

which included chronic thrombosis causing severe luminal narrowing

in the draining vein. Other less common cause included anastomotic

site thrombosis/stenosis (10%).

NUMBER PERCENTAGE

Venous thrombosis 11 55%

Venous stenosis 7 35%

Anastomotic site 2 10%

stenosis/thrombosis
TOTAL 20 100%

Table 10 : Causes of Secondary Fistula Failure

Causes of Secondary Fistula Failure

60%

50%

40%

30%

20%

10%

0%
Venous thrombosis Venous stenosis Anastomotic site
stenosis/thrombosis

Causes of Secondary Fistula Failure

Graph 10 : Causes of Secondary Fistula Failure

Acute and subacute venous thromboses were identified as lumen

occluding echogenic content within the veins with increased or

preserved vein diameter and surrounding subcutaneous fat

inflammatory changes. Chronic thrombosis amounting to stenosis was

identified as lumen occluding echogenic content within the veins with

significantly narrowed vein diameter and presence of surrounding

collaterals for blood run-off.

The above chart shows that the most common site for complications

leading to secondary fistula failure was the draining vein. This is in

keeping with the fact that the draining vein is cannulated with arterial

and venous end canulae at each dialysis. Repeated instrumentation of

the draining vein leads to vascular endothelial injury causing

occlusive disease or aneurysmal dilatation of the draining vein.

Another less common site for complications leading to fistula failure

was the anastomotic site. This can be attributed either to delayed

surgical complications or to the altered hemodynamics causing

turbulent flow across the anastomotic site leading to

thrombosis/stenosis.

Complications in patients with Adequate Fistula Flow

Of the 8 patients with Adequate fistula flow on doppler studies, 6

patients presented with complaints of local swelling or palm swelling

which was attributed to venous aneurysms and Steal phenomenon

respectively. 2 patients presented with complaints of inadequate flow

during dialysis but had adequate draining vein flow volume on

doppler studies with multiple draining vein collaterals. This was

attributed to probable cannulation of one of the non-arterialised

collaterals leading to inadequate flow during dialysis.

 NUMBER PERCENTAGE

Collaterals 2 25%

Venous aneurysm/varix 2 25%

Steal phenomenon 3 37.5%

Fistula site collection 1 12.5%

TOTAL 8 100%

Table 11 : Complications in patients with Adequate Fistula Flow

Complications in Adequate Fistula Flow

40%

35%

30%

25%

20%

15%

10%

5%

0%
Multiple Collaterals Venous aneurysm/varix Steal Phenomenon Fistula Site Collection

Complications in Adequate Fistula Flow

Graph 11 : Complications in patients with Adequate Fistula Flow

There were a total of 3 patients with Steal phenomenon in the study.

Steal phenomenon is a possible complication of AV access fistulae

wherein there is symptomatic or asymptomatic distal ischemia in the

hand due to excess arterial flow across the fistula site into the draining
vein. There is resultant retrograde flow in the distal arterial segment

beyond the fistula site via the ulnar artery and palmar arch. All 3 of

these patients had presented with swelling of the hand with

paraesthesia without signs of gangrene on examination suggesting

low grades of Arterial Steal.

Interestingly, 2 other patients also had retrograde flow in the distal

radial artery beyond the fistula site; one of these was found to have

fistula site and juxta-anastomotic proximal radial artery thrombosis

and the other was an operated case of proximal radial artery excision

due to ruptured radial artery aneurysm. In both these patients, there

was retrograde flow in the distal artery feeding the fistula via the

palmar arch.

Venous aneurysms were attributed to weakening of the draining vein

wall due to repeated cannulation causing blow-out at the puncture

sites.

Classification of patients based on Fistula outcome

NUMBER PERCENTAGE
Functional following non- 11 25%

surgical intervention

Abandoned fistula 17 38.6%

Functional following endo- 8 18.2%

vascular intervention

Fistula shut down by open 7 15.9%

surgery

Lost to follow up 1 2.3%

TOTAL 44 100%

Table 12 : Classification of patients based on Fistula outcome

Fistula Outcome
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Functional following Abandoned fistula Functional following Fistula shut down by Lost to follow up
non-surgical endo-vascular open surgery
intervention intervention

Fistula Outcome

Graph 12 : Classification of patients based on Fistula outcome

The patients that underwent open vascular surgery for closing-down

the fistula (15.9%) included those with feeding artery aneurysms,

Steal phenomenon and sealed-off rupture of venous varices.

The patients that underwent endo-vascular intervention (18.2%)

included those with short-segment (< 2.5 cm) draining vein

thrombosis or stenosis and one patient with CVO.

All 8 patients who underwent Fistulograms by Digital Subtraction

Angiography had findings corroborating with the ultrasound and

doppler studies.

However, a lot of patients with fistula site or draining vein stenosis

amenable to endo-vascular therapy did not undergo the treatment due

to financial constraints and their fistulae were abandoned.

Unfortunately one patient was lost to follow-up.

Limitations

This study has several limitations. Firstly, the sample size was small

due to the availability of peripheral hemodialysis centers with

specialised Arterio-venous fistula care and referral of limited

complicated to our tertiary care center.

Additionally, a large number of our patients underwent fistula

abandonment and creation of a new Arterio-venous fistula for

hemodialysis. This meant that these patients did not undergo a Digital

Subtraction Angiography Fistulogram to identify the thrombosis or

stenosed segment either due to cost considerations or accessibility and

hence the results of the ultrasonography and doppler studies could not

be corroborated with DSA in all cases which is considered the gold

standard for evaluation.

Also, being a descriptive study, it did not include a comparative

analysis of CT angiography or DSA and flow volumes during doppler

study which would better depict the sensitivity and specificity of

ultrasonography and doppler studies in identification of Arterio-

venous fistula complications.

 DISCUSSION

In a prospective study by Hassan et al including 60 patients referred

to primary and tertiary centers, 33 patients (55%) had complicated

Arterio-venous fistulae. At both centers, the most prevalent

complications were thrombosis and stenosis with high incidence of

aneurysm formation and hematoma as well. The study evaluated the

use of ultrasonography and color doppler study as a first line imaging

modality due to low cost and availability (101).

In a retrospective study of 437 patients by Demiral et al, a 4 year

follow up was maintained to analyse the findings on ultrasonography

and color doppler study. The preferred type of surgery was an end-to-

side anastomosis. Majority fistulae were radio-cephalic (~ 61%)

followed by brachio-cephalic (~ 25%). The most common early

complications occurring at < 48 hours were thrombosis (~ 70%)

followed by lesser incidence of hemorrhage. The most common late

complications encountered at > 48 hours were thrombosis/stenosis (~

40%) followed by aneurysmal dilatation, hematomas and arterial steal

syndrome to lesser degrees (102).

In a prospective study by Meyer et al, 35 patients were included to

compare the findings in complicated Arterio-venous fistulae at

ultrasonography and color doppler and CT Angiography with surgery

taken as the gold standard. It was found that the 35 patients had a total

of 53 pathologies, the most common of which was thrombosis of the

fistula. Duplex ultrasound had 42 true positives, 12 false negatives

and 2 false positives showing a sensitivity of ~ 78%. Ct angiography

on the other hand had a sensitivity of 100% suggesting that it is an

important non-invasive diagnostic tool to detect complications that

may be missed on duplex ultrasound prior to invasive digital

subtraction angiography (103).

In a study by Cansu et al including 41 patients, of which 35 had

Arterio-venous fistulae and 6 had Arterio-venous grafts, patients were

evaluated by ultrasonography and color doppler and followed by

either surgery or digital subtraction angiography as the gold standard.

Including both categories, the most prevalent complication was

stenosis (~55%) followed by equal prevalence of thrombosis and

aneurysmal dilatation (~ 19%). Using DSA or surgery as gold

standard, duplex ultrasound had sensitivity of ~ 86% and a specificity

of ~ 99% while CT angiography had a sensitivity of ~ 97% and a

specificity of ~ 99%. However, when both modalities were used in

tandem, both specificity and sensitivity were 100% (104).

Our study found a similar incidence of complications causing both

primary and secondary fistula failure throughout the study population

as the above-mentioned studies.

 CONCLUSION

Ultrasonography with doppler study is the first-line imaging

technique in diagnosing and working up early and late Arterio-venous

fistula complications. It provides useful information on the

morphology and the function of vascular access. Furthermore, it can

be used in the nephrology point of care of ultrasound and bedside

whenever imaging is needed to integrate the physical examination or

validate a complication’s clinical suspicion. The study shows that the

preferred site for Arterio-venous fistula creation is the non-dominant

hand and at a distal location in the form of radio-caphalic Arterio-

venous fistulae. The chief presenting complaint for radiological

evaluation is low flow in the fistula during hemodialysis. The

predominant causes for primary fistula failure/non-maturation are

anastomotic site or juxta-anastomotic venous stenosis/thrombosis.

The predominant causes for secondary fistula failure are venous

thrombosis or stenosis. The prevalent complications in patients with

adequate fistula flow on ultrasonography and doppler studies are steal

phenomenon, multiple collaterals and venous and arterial aneurysms.

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Access 2015;16(3):255–257.

100. Cordova E, Pettorini L, Scrivano J, et al. Preoperative duplex

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Access 2015;16(3):255–257.

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importance of color Doppler ultrasonography in puncture related

complications of hemodialysis vascular access. Egypt J Radiol Nucl

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102. Serdar Demiral, Ozlem Turkoglu, Zafer Turkoglu.

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[Link]
 ANNEXURES

CASE RECORD FORM

Age:

Sex:

Type of fistula:

Date of fistula creation:

Clinical diagnosis:

Physical fistula examination:

Hemo-dialysis flow:

USG findings:
Parameter Feeding Anastomotic Draining Vein

Artery Site

Diameter of vessel

Depth from skin

Vessel wall

characteristics

PSV (cm/sec)

Flow volume

(ml/min)

Collaterals

Tortuosity/thrombosis

Additional Comments:

Signature:
 INFORMED CONSENT DOCUMENT

[Link]:

You are invited to participate in a research study. It is

important that you read the description of this study and

understand your role in it, including the nature and risks of

participation.

Please give your consent to participate in this clinical study only

if you have completely understood the nature and course of this

study and if you are aware of your rights as a participant.

2. Purpose of the study:

Doppler Ultrasound is the diagnostic investigation for

complications of Arterio-venous Access Fistulae and

evaluation of causes of access failure. It guides therapeutic

interventions. It is a low-cost investigation which is available at

all primary care centers.

This study aims to describe the various possible complications

of AV access fistulae encountered in a tertiary care center.

[Link] duration of study and number of subjects:

You will be one of approximately 42 people who will participate in

this study.

[Link] procedures to be followed:

The patients who agree to participate in this study will be asked

about their current complaints, history of the AV fistula being

evaluated and any laboratory and radiological investigation if done

will be recorded. An ultrasound doppler of the AV fistula will be

performed. The doppler ultrasound will be done as requested by your

treating doctor. Data obtained from this doppler ultrasound will be

used for study purpose.

[Link] duration of study:

For each ultrasound examination approximately 10-15 minutes will

be required.
[Link] and discomforts of participating:

There is no risk of radiation exposure during the ultrasound. As

this is a purely observational study no intervention will be done.

The study will cause no harm as no additional scan or procedure

will be done besides ultrasound.

[Link] benefits of the study:

By participating in this study the possible complications and

causes of AV fistula failure can be detected on doppler

ultrasound, which is cost effective and can be done at the point of

care. The doppler ultrasound is the diagnostic investigation for

AV fistulae and guides intervention when necessary. Participation

in this study will provide information that will help other patients

suffering from the same disease.

[Link] for participation:

Participation in this study will be at no cost to you.

No compensation will be provided for your participation as the

doppler ultrasound will be done as requested by your treating

doctor. No separate visits to the hospital will be required for the

ultrasound. Payment for things such as lost wages will not be

available.

[Link] to withdraw from the study:

Participation in this study is entirely voluntary. You may choose

not be participating in the study. Your decision will not affect

your further treatment in this institute.

[Link]:

All study records will be kept confidential at all times. Your

identity will not be revealed except as required by law. The

results of this study may be published for scientific reasons.

Your identity will not be revealed in these publications.

[Link] for further information:

Thank you for taking the time to read (or have read to you) the

information about this study. Before you should sign this

document, you should ask questions about anything that you do

not understand. The study staff will answer all your questions

before, during, and after the study.

If you have questions about this study or how it is being run, you

can contact the study doctor

______________, Department of Radiology at telephone no:

__________ during office hours or at __________ outside the office

hours.

If you have any questions about your rights as a research

participant, or complaints regarding the research study, you should

call the Member Secretary of the Committee for Academic

Research Ethics on the following telephone number on working

days. Tel No.:

__________ (Monday to Friday – 9:00 am to 4:00 pm; Saturday –

 9:00 am

to 1:00 pm)

Consent

I have read or have had read to me the information given in the

informed consent document for the study entitled “Descriptive Study

of Ultrasound and Doppler Evaluation of Complications of Arterio-

Venous Access Fistulae”.

1.I have received an explanation of the nature, purpose, duration,

foreseeable effects, risks of trial and what I will be expected to do.

My questions have been answered satisfactorily.

2.I understand that my participation in this trial is voluntary and that

I may refuse to participate or may withdraw from the trial at any

time, without penalty or loss of benefits to which I am otherwise

entitled.

3.I further understand that any information that becomes available

during the study that may affect my willingness to take part will be

informed to me.
4. Institutional review board authorities may wish to examine my

medical records to verify the information collected. By signing this

document, I permit this review of my records.

5. I understand that my identity will not be revealed in any report or

publication.

6. I agree to take part in the above study.

Name of subject Signature/thumb impression. Date

Name of Legal representative Relation to subject

Signature Date
Name of Impartial witness Signature of impartial witness Date

Name of the person Signature of the person Date

Administering consent Administering consent

 ABBREVIATIONS

CKD = Chronic Kidney Disease

AVF = Arterio-Venous Fistula

AVG = Arterio-Venous Graft

PD = Peritoneal Dialysis

HD = Hemo-Dialysis

CVC = Central Venous Catheter

USG = Ultrasonography

KDIGO = Kidney Disease: Improving Global Outcomes

PTFE = Poly Tetra Fluoro Ethylene

MASTERCHART