Perioperative ultrasound: a critical element in diagnosis and salvage of complex vascular access dysfunction



Perioperative ultrasound performed by the operative surgeon can improve outcomes of vascular access surgery. We present the case of a patient referred for dysfunctional vascular access with two separate and patent right arm arteriovenous fistulas (AVF). Pre-operative ultrasound vessel mapping defined the complex anatomy and intraoperative ultrasound allowed the optimal surgical approach for access salvage while avoiding the need for catheter placement.

Case report

A 45-year-old male patient of African descent presented with a malfunctioning right forearm AVF and aneurysm formation in the arm. Clinical examination revealed a soft, low-flow forearm fistula merging into a high-flow and pulsatile AVF outflow aneurysm in the arm. Multiple well healed surgical incisions were present. Ultrasound examination revealed two separate AVFs. One was a low-flow radiocephalic AVF at the wrist that was used routinely for cannulation in the forearm, although with some difficulty due to low inflow pressure. The second AVF, a brachiocephalic anastomosis, was pulsatile, aneurysmal, and not in use. Blood flow in the proximal brachial artery was 3.0 L/min. Surgeon-performed ultrasound (SP-US) was used perioperatively to plan the surgical approach and incision, closing the existing brachial anastomosis and creating a veno-venous anastomosis between both outflow veins, establishing a mature and undisturbed cannulation conduit from the wrist through the arm. The revised AVF was immediately usable for hemodialysis with restored normal AVF flow in the forearm and appropriately reduced flow in the arm. Importantly, dialysis catheter placement was avoided.

J Vasc Access 2017; 18(4): 359 - 361




Alexandros Mallios, Hadia Hebibi, William Jennings

Article History


Financial support: No grants or funding have been received for this study.
Conflict of interest: None of the authors has financial interest related to this study to disclose.

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Arteriovenous fistulas (AVF) provide the best means of vascular access for hemodialysis in patients with end-stage renal disease (1, 2). The role of ultrasound (US) for planning vascular access surgery is well established (3). Many surgeons plan operative procedures based on reports provided by technicians or other physicians and this multidisciplinary approach can offer improved vascular access outcomes when creating new AVFs. This reported case illustrates how preoperative vascular mapping and perioperative US performed by the operative surgeon (SP-US) contributes important information for planning and completing access operations allowing for optimization of results, especially for access salvage in complex vascular access revision procedures.

Case report

A 45-year-old patient of African ancestry was referred for evaluation of a dysfunctional right forearm AVF. The patient’s cause of renal failure was focal segmental glomerulosclerosis, requiring dialysis since 2007. He was unable to provide any significant account of previous surgical interventions and records were not available. Clinical examination revealed various surgical scars and a distal radiocephalic AVF with a faint thrill that was being cannulated for hemodialysis. In addition, an aneurysmal proximal cephalic vein in the arm was present with a strong thrill and pulsatile element indicating a high-flow fistula. A duplex US scan surprisingly revealed two completely separate AVFs: (i) A distal low-flow (250 mL/min) radiocephalic AVF draining through a 6 - mm tortuous median antebrachial vein with outflow through the median cubital and eventually the basilic vein. (ii) A second and completely separate brachiocephalic fistula was also present and had developed excessive flow (2750 mL/min). The overall flow measured by SP-US in the proximal brachial artery was approximately 3 L/min (Fig. 1). SP-US showed normal radial and ulnar arteries and a widely patent (8 mm) radiocephalic AVF anastomosis. After SP-US identified the separate brachiocephalic AVF, it’s outflow could be digitally occluded, resulting in immediate restoration of adequate AVF flow through the distal radiocephalic anastomosis, an important factor in planning the surgical revision. SP-US identified the radiocephalic AVF outflow through the median cubital vein in close proximity to the high-flow brachiocephalic AVF anastomosis. This finding was the final component in planning the optimal surgical management. Using SP-US to carefully locate the incision site, the brachiocephalic AVF anastomosis was dissected free and divided after appropriate heparin administration and application of vascular clamps. The brachiocephalic AVF stump was closed at the brachial artery using 6-0 running polypropylene suture, taking care to avoid narrowing of the artery. The median cubital vein was isolated and controlled through the same incision. An end-to-side anastomosis between the distal radiocephalic fistula outflow (the median cubital vein) to the aneurysmal proximal cephalic vein established a single functional radiocephalic AVF. The continuation of the median cubital vein into the basilic vein was left open as secondary outflow should the proximal cephalic vein thrombose due to decreased flow (Figs. 2 and 3). The patient’s recovery was uneventful and the entire revised AVF conduit remains patent with an overall flow of approximately 1 L/min as evaluated by duplex scan 3 and 6 months postoperatively (Fig. 4). The salvaged AVF was immediately available for cannulation and a temporary dialysis catheter was not required.

Preoperative picture of the patient’s arm with schematic illustration of the two separate fistulas. The ultrasound flow measurement (proximal brachial artery) can be seen in the upper left corner. Circled numerical markers on the schematic illustration are: 1) radiocephalic AVF, 2) median cubital vein, 3) brachiocephalic AVF, 4) ulnar artery, 5) brachial artery.

Intraoperative picture with schematic illustration showing the incision site at the median aspect of patient’s right elbow. Note the brachiocephalic anastomosis in addition to the median cubital vein that is draining the forearm fistula into the basilic vein. Circled numerical markers on the schematic illustration are: 2) median cubital vein, 3) brachiocephalic AVF, 5) brachial artery.

Intraoperative picture with schematic illustration showing the final aspect of reconstruction of both vascular accesses into a single AVF. The brachiocephalic anastomosis was ligated at the level of the artery. The median cubital vein and the stump of the cephalic vein were anastomosed in an end-to-side configuration. The patient now has a single functioning distal radiocephalic fistula draining into both the cephalic and basilic veins. Circled numerical markers on the schematic illustration are: 2) median cubital vein, 3) brachiocephalic AVF, 5) brachial artery.

Postoperative picture of the patient’s arm shows the well healed incision with schematic illustration of patient’s reconstructed vascular access. Note that in comparison to Figure 1, the skin over the underlying cephalic vein is less distended and under less tension. The ultrasound flow measurement (proximal brachial artery) is shown in the left upper corner. Circled numerical markers on this schematic illustration are: 1) radiocephalic AVF, 2) median cubital vein, 3) cephalic vein, 4) ulnar artery, 5) brachial artery, and 6) basilic vein.


An AVF is the best option for long-term vascular access patients requiring hemodialysis in terms of long-term access patency, fewer complications, fewer hospitalizations, and lower costs (1, 2). The use of ultrasound is of paramount importance for planning the creation or the revision of an AVF (3). US vascular mapping studies done by other health-care providers with a detailed report are helpful. However, preoperative mapping and perioperative US completed by the operative surgeon provides the most information and insight regarding quality, exact location, and surgical opportunity of different vessels. This SP-US may contribute substantially to success or failure of a vascular access procedure, especially when considering salvage of a complex AVF (4). Even very subtle findings may be critical in discovering a more limited revision option with greater opportunity for success, leaving mature cannulation sites undisturbed and avoiding catheter exposure.

A vascular access developing excessively high flow is not rare, especially with brachial artery inflow. High-flow access occurs most commonly in younger patients where the artery is more compliant and may rapidly increase in size after access creation. While a high-flow AVF may be easier to cannulate, eventually these AVFs create both local and systemic complications (4-5-6). Aneurysm formation, delayed hemostasis post-cannulation, and/or major bleeding are often related to a high-flow vascular access. In some patients, elevated access pressure in these high-flow AVFs may be due solely to elevated blood flow, even without outflow stenosis. We have observed this finding through examination, US, and fistulograms in other patients and believe that the excessive flow in some individuals simply cannot be accommodated by existing “normal” venous outflow. The long-term risk of heart failure is an important systemic risk with compelling evidence to support flow reduction for fistulas with flow >2 L/min and even for some selected patients with flow >1.5 L/min (5, 7).

Many patients are not able to provide a full account of previous operations and written records may be unavailable or unclear. When faced with such a complex presentation, SP-US is a critical element in understanding the existing dysfunctional access and devising a plan for salvage of a safe and functional AVF. Our patient was unexpectedly found to have two completely separate AVFs. The radiocephalic AVF was in use with low flow due to the high-flow proximal access. In addition, the unused brachiocephalic AVF posed a long-term risk for heart failure and was responsible for proximal aneurysm development. An important aspect of planning an AVF revision includes maintaining access cannulation sites when possible, thereby avoiding catheter placement. SP-US allowed planning the operation and placement of the incision for this patient to protect mature cannulation sites.

This procedure was performed as an outpatient and the patient’s recovery was uneventful. The AVF was used without difficulty the day following surgery and is currently functional after nine months. The access has been reliably cannulated without problems and without further interventions. Ultrasound at 3 and 6 months confirmed patency of the entire access circuit and consistent overall flow reduction with restoration of functional flow in the forearm cannulation zone.


Financial support: No grants or funding have been received for this study.
Conflict of interest: None of the authors has financial interest related to this study to disclose.
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  •  Department of Vascular Surgery, Institut Mutualiste Montsouris, Paris - France
  •  Polyclinique de Villeneuve St. George, Ramsay – Generale de Sante, Villeneuve St. George - France
  •  Hemodialysis Unit, Nephrocare, Bievres - France
  •  Nephrology Department, University Hospital, Kremlin-Bicêtre, Paris - France
  •  Department of Surgery, University of Oklahoma College of Medicine, Tulsa, OK - USA

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