From the Guidelines
Fistulography is the recommended imaging modality to confirm femoral arteriovenous (AV) dialysis access placement, as it provides a comprehensive evaluation of the entire hemodialysis vascular access circuit and allows for simultaneous diagnostic and therapeutic interventions 1. To confirm femoral AV dialysis access placement, fistulography should be performed to assess the patency of the hemodialysis vascular access circuit, including the arterial inflow, anastomosis site, and venous outflow. Specific details:
- Fistulography can be performed by an interventional radiologist, vascular surgeon, or interventional nephrologist
- The procedure involves injecting iodinated contrast material to visualize the access lumen and assess for hemodynamically significant stenoses
- Multiple projections may be performed to better visualize the access lumen and assess for the presence of stenoses Additional considerations:
- Digital subtraction angiography (DSA) may also be used, but it has limitations in detecting stenoses in certain areas, such as the juxta-anastomotic segments
- Carbon dioxide may not be as reliable in assessing venous anatomy and may overestimate the extent of a visualized stenosis Justification: Fistulography is the reference standard for imaging a dysfunctional dialysis access, as it provides high diagnostic accuracy and allows for simultaneous percutaneous endovascular interventions 1. It is also recommended by the Society of Interventional Radiology’s (SIR) Quality Improvement Guidelines and the European Best Practice Guidelines Expert Group on Hemodialysis 1.
From the Research
Imaging Modality for Confirming Femoral Arteriovenous (AV) Dialysis Access Placement
To confirm femoral arteriovenous (AV) dialysis access placement, the following imaging modalities can be used:
- Ultrasound guidance is recommended for vascular access procedures, including femoral arteriovenous (AV) dialysis access placement 2
- Real-time ultrasound guidance with a high-frequency linear transducer can be used for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications 2
- Ultrasound imaging can be used to evaluate femoral vein structures and examine anatomical variations in uraemic patients, which can impact vascular access 3
- Ultrasound-guided cannulation of the femoral vein has been shown to be superior to traditional techniques relying on anatomic landmark, reducing the numbers of unsuccessful attempts and the possible acute complications of the procedure 4, 5
Key Findings
- Ultrasound-guided cannulation of the femoral vein can achieve a 100% success rate in catheter placement after ultrasound assessment of one central vein 6
- The use of ultrasound to assess the central veins facilitates the identification of veins suitable for catheterization and the avoidance of occluded central veins 6
- Ultrasound-guided cannulation of the femoral vein reduces the time required for the procedure, reduces the number of passes needed to puncture the vein, and minimizes complications such as arterial puncture or hematoma 5
Recommendations
- Providers should use real-time ultrasound guidance for femoral arteriovenous (AV) dialysis access placement to increase first-pass success rates and reduce the risk of vascular complications 2
- Ultrasound imaging should be used to evaluate femoral vein structures and examine anatomical variations in uraemic patients to impact vascular access 3
- Ultrasound-guided cannulation of the femoral vein should be used instead of traditional techniques relying on anatomic landmark to reduce the numbers of unsuccessful attempts and the possible acute complications of the procedure 4, 5