How to Order Vascular Surgery AVF Consultation for Aneurysm
Order a vascular surgery consultation for AVF aneurysm by requesting duplex ultrasound imaging with specific aneurysm protocol measurements, documenting clinical risk factors (skin integrity, symptoms, rapid growth), and obtaining proactive surgical assessment when findings suggest risk of complications. 1, 2
Initial Imaging Order
Begin with duplex Doppler ultrasound as the primary imaging modality, explicitly specifying "aneurysm protocol" rather than generic "AVF ultrasound." 2 The order must request:
- Aneurysm measurements: absolute diameter in centimeters, ratio to native vessel diameter, length of aneurysmal segment, and distance from arterial anastomosis 2
- Flow parameters: absolute flow rate in mL/min, comparison to baseline access flow, peak systolic velocity, and flow patterns suggesting stenosis 2
- Associated pathology: presence of thrombus, stenosis location and severity (particularly post-aneurysmal stenosis), and intra-access pressure 2
- Central venous evaluation: assessment of central veins, as 9% of AVF aneurysms have central venous stenosis affecting management 2
Clinical Documentation Required for Consultation
Document specific risk stratification elements that guide surgical decision-making:
High-Risk Features Requiring Urgent Surgical Assessment 1, 2
- Skin integrity: thin, shiny skin overlying the aneurysm indicates impending rupture risk 1, 2
- Rapid expansion: progressive enlargement over serial examinations 1, 2
- Size criteria: aneurysms >3 cm diameter 2
- Symptomatic features: pain, skin breakdown, erosion, or hemorrhage 1
- Functional compromise: inadequate straight segments for two-needle cannulation 2
Emergent vs. Proactive Referral
- Emergent surgical assessment: required for aneurysm complications including erosion or hemorrhage 1
- Proactive surgical assessment: indicated when clinical findings suggest aneurysm at risk of complications (symptomatic or skin breakdown) 1
Fistulography Indications
Order fistulography when:
- Duplex ultrasound suggests hemodynamically significant stenosis requiring intervention 2
- Endovascular treatment is being planned 2
- Complete anatomic mapping is needed for surgical planning 2
- Ultrasound findings are inconclusive 2
Key Information for Surgical Consultation
Include in the consultation request:
Aneurysm Characteristics
- Type: true aneurysm vs. pseudoaneurysm (anastomotic aneurysms typically require definitive surgical treatment) 1
- Location: juxta-anastomotic position, within cannulation areas, or along venous outflow tract 1
- Associated stenosis: particularly post-aneurysmal stenosis that drives aneurysm formation 1
Access History
- Duration of AVF function 1
- Cannulation patterns (repeated "1-site-itis" cannulation predisposes to aneurysm formation) 1
- Previous interventions or thrombosis episodes 1
- Current dialysis adequacy (flow rates, Kt/V) 1
Patient-Specific Factors
- Alternative cannulation sites available 1
- Alternative access options if repair fails 1
- Comorbidities affecting surgical risk 1
Critical Pitfalls to Avoid
Do not order generic "AVF ultrasound" without specifying aneurysm protocol with size documentation, as this leads to inadequate imaging for surgical planning. 2
Do not delay imaging or referral when clinical examination reveals thin skin, rapid enlargement, or symptoms, as these indicate high rupture risk. 1, 2
Do not omit assessment of inflow and outflow vessels, as stenosis (particularly post-aneurysmal stenosis) must be corrected during definitive treatment to prevent recurrence. 1
Do not continue cannulating the aneurysmal segment while awaiting consultation, as this increases rupture risk; alternative sites should be used if available. 1
Management Expectations
Asymptomatic aneurysms alone do not require definitive treatment, but warrant close monitoring and avoidance of cannulation in that segment. 1 However, surgical management is preferred for symptomatic, large, or rapidly expanding aneurysms, with open surgical treatment as the definitive approach. 1 The specific surgical technique (aneurysmorrhaphy, staged repair of multiple aneurysms) will be determined by the vascular surgeon based on local expertise and individual anatomy. 1
Educate the patient on emergency procedures for aneurysm rupture (direct pressure, emergency contact) while awaiting consultation. 1