What is the necessary workup for a patient with potential vascular complications after access site creation?

Workup for Potential Vascular Complications After Access Site Creation

The necessary workup for a patient with potential vascular complications after access site creation should include both subjective assessment of symptoms and objective physical examination, with urgent referral to a vascular access surgeon for moderate to severe signs of ischemia.

Initial Assessment (First 24 Hours Post-Procedure)

Subjective Assessment

• Obtain detailed history of symptoms, particularly focusing on:
  • Sensations of coldness in the limb 1
  • Numbness or tingling 1
  • Pain, especially during dialysis 1
  • Impairment of motor function not explained by post-operative pain 1

Objective Physical Examination

• Compare affected limb with contralateral side for: 1
  • Skin temperature (decreased temperature may indicate reduced perfusion) 1
  • Gross sensation (assess for decreased sensitivity) 1
  • Motor function (check for weakness or impaired movement) 1
  • Distal arterial pulses (diminished or absent pulses suggest vascular compromise) 1
  • Presence of edema (may indicate venous outflow problems) 1
  • Examination of the access site for abnormal bruit or thrill 1
  • Assessment for collateral veins (indicative of venous obstruction) 1

High-Risk Patient Monitoring

Patients requiring closer monitoring include:

• Diabetic patients 1
• Elderly patients 1
• Patients with multiple previous access attempts in the same extremity 1
• Patients with increased BMI (associated with higher risk of vascular injury) 2
• Patients with open injuries 2
• Patients with abnormal arterial supply due to:
  • Prior vascular access 1
  • Vascular anomalies 1
  • Atherosclerotic disease 1

Ongoing Monitoring (Established Access)

Monthly Assessment

• Obtain interval history of: 1
  • Increased distal coldness 1
  • Distal pain during dialysis 1
  • Decreased sensation 1
  • Weakness or other reduction in function 1
  • Skin changes 1
• Confirm any abnormalities through physical examination 1
• Check the access site before every cannulation or connection for potential complications 1

Diagnostic Testing

When to Pursue Additional Testing

• Abnormal physical examination findings 3, 2
• Symptoms suggesting ischemia 1
• Suspected stenosis or thrombosis 1

Appropriate Tests May Include:

• Doppler ultrasound evaluation for:
  • Access blood flow (Qa) measurement 1
  • Detection of stenosis 1
  • Assessment of peripheral circulation 4
• Ankle-brachial index (ABI) - values <0.9 suggest significant vascular compromise 2
• Arteriography - rarely required but useful to avoid extremity ischemia in patients with diminished pulses 1
• Transcutaneous oxygen evaluation to assess tissue hypoxia in suspected ischemic wounds 4

When to Refer for Urgent Intervention

Immediate Referral Criteria

• New findings suggestive of ischemia (coldness, loss of motion, significant reduction in sensation) 1
• Moderate to severe signs and symptoms of AV access steal 1
• Signs of infection involving the vascular access 1
• Rapidly expanding aneurysm/pseudoaneurysm 1
• Absent pulses with clinical signs of ischemia 2

Observation Criteria

• Reduced skin temperature as an isolated finding requires follow-up but not emergent intervention 1
• Mild to moderate signs and symptoms of AV access steal require close monitoring for progression 1

Common Pitfalls and Caveats

• Physical examination alone is highly sensitive for detecting significant vascular injuries when performed properly 3, 5, 2
• The combination of palpable dorsalis pedis and posterior tibial pulses with an ABI ≥0.9 has been shown to be 100% sensitive for ruling out vascular injury 2
• Severe ischemia can cause irreparable nerve injury within hours and must be considered a surgical emergency 1
• Mild ischemia (subjective coldness, paresthesias, reduced skin temperature without loss of sensation or motion) is common and generally improves with time 1
• Patients with mild ischemia should receive symptom-specific therapy (e.g., wearing a glove) and frequent physical examination with attention to subtle neurological changes and muscle wasting 1