Semin intervent Radiol 2009; 26(2): 130-138
DOI: 10.1055/s-0029-1222457
© Thieme Medical Publishers

Surveillance of Hemodialysis Vascular Access

William L. Whittier1
  • 1Department of Internal Medicine, Division of Nephrology, Rush University Medical Center, Chicago, Illinois
Further Information

Publication History

Publication Date:
29 June 2009 (online)


A mature, functional arteriovenous (AV) access is the lifeline for a hemodialysis (HD) patient as it provides sufficient enough blood flow for adequate dialysis. As the chronic kidney disease (CKD) and end-stage renal disease (ESRD) population is expanding, and because of the well-recognized hazardous complications of dialysis catheters, the projected placement and use of AV accesses for HD is on the rise. Although a superior access than catheters, AV accesses are not without complications. The primary complication that causes AV accesses to fail is stenosis with subsequent thrombosis. Surveying for stenosis can be performed in a variety of ways. Clinical monitoring, measuring flow, determining pressure, and measuring recirculation are all methods that show promise. In addition, stenosis can be directly visualized, through noninvasive techniques such as color duplex imaging, or through minimally invasive venography. Each method of screening has its advantages and disadvantages, and several studies exist which attempt to answer the question of which test is the most useful. Ultimately, to maintain the functionality of the access for the HD patient, a team approach becomes imperative. The collaboration and cooperation of the patient, nephrologist, dialysis nurse and technician, vascular access coordinator, interventionalist, and vascular surgeon is necessary to preserve this lifeline.


  • 1 United States Renal Data System .2007 Annual Data Report. Bethesda, MD; U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health 2007
  • 2 Astor B C, Eustace J A, Powe N R, Klag M J, Fink N E, Coresh J. CHOICE Study . Type of vascular access and survival among incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study.  J Am Soc Nephrol. 2005;  16(5) 1449-1455
  • 3 Lee T, Barker J, Allon M. Tunneled catheters in hemodialysis patients: reasons and subsequent outcomes.  Am J Kidney Dis. 2005;  46(3) 501-508
  • 4 Maya I D, Oser R, Saddekni S, Barker J, Allon M. Vascular access stenosis: comparison of arteriovenous grafts and fistulas.  Am J Kidney Dis. 2004;  44(5) 859-865
  • 5 Vascular Access 2006 Work Group . Clinical practice guidelines for vascular access.  Am J Kidney Dis. 2006;  48(Suppl 1) S176-S247
  • 6 Tonnessen B H, Money S R. Embracing the fistula first national vascular access improvement initiative.  J Vasc Surg. 2005;  42(3) 585-586
  • 7 Basile C, Lomonte C, Vernaglione L, Casucci F, Antonelli M, Losurdo N. The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients.  Nephrol Dial Transplant. 2008;  23(1) 282-287
  • 8 Miller C D, Robbin M L, Barker J, Allon M. Comparison of arteriovenous grafts in the thigh and upper extremities in hemodialysis patients.  J Am Soc Nephrol. 2003;  14(11) 2942-2947
  • 9 Miller P E, Carlton D, Deierhoi M H, Redden D T, Allon M. Natural history of arteriovenous grafts in hemodialysis patients.  Am J Kidney Dis. 2000;  36(1) 68-74
  • 10 Lilly R Z, Carlton D, Barker J et al.. Predictors of arteriovenous graft patency after radiologic intervention in hemodialysis patients.  Am J Kidney Dis. 2001;  37(5) 945-953
  • 11 Beathard G A. An algorithm for the physical examination of early fistula failure.  Semin Dial. 2005;  18(4) 331-335
  • 12 Besarab A, Sherman R. The relationship of recirculation to access blood flow.  Am J Kidney Dis. 1997;  29(2) 223-229
  • 13 Alloatti S, Molino A, Bonfant G, Ratibondi S, Bosticardo G M. Measurement of vascular access recirculation unaffected by cardiopulmonary recirculation: evaluation of an ultrasound method.  Nephron. 1999;  81(1) 25-30
  • 14 Depner T A, Krivitski N M, MacGibbon D. Hemodialysis access recirculation measured by ultrasound dilution.  ASAIO J. 1995;  41(3) M749-M753
  • 15 Depner T A, Krivitski N M. Clinical measurement of blood flow in hemodialysis access fistulae and grafts by ultrasound dilution.  ASAIO J. 1995;  41(3) M745-M749
  • 16 Brancaccio D, Tessitore N, Carpani P et al.. Potassium-based dilutional method to measure hemodialysis access recirculation.  Int J Artif Organs. 2001;  24(9) 606-613
  • 17 Mercadal L, Coevoet B, Albadawy M et al.. Analysis of the optical concentration curve to detect access recirculation.  Kidney Int. 2006;  69(4) 769-771
  • 18 Alloatti S, Magnasco A, Bonfant G, Pellu V, Paroli V. Comparison of glucose pump test and urea test in measuring blood access flow.  J Nephrol. 2004;  17(4) 559-564
  • 19 Magnasco A, Alloatti S, Bonfant G, Copello F, Solari P. Glucose infusion test: a new screening test for vascular access recirculation.  Kidney Int. 2000;  57(5) 2123-2128
  • 20 Sherman R A. The measurement of dialysis access recirculation.  Am J Kidney Dis. 1993;  22(4) 616-621
  • 21 Krivitski N M. Theory and validation of access flow measurement by dilution technique during hemodialysis.  Kidney Int. 1995;  48(1) 244-250
  • 22 Besarab A, Lubkowski T, Frinak S, Ramanathan S, Escobar F. Detection of access strictures and outlet stenoses in vascular accesses. Which test is best?.  ASAIO J. 1997;  43(5) M543-M547
  • 23 Lindsay R M, Sternby J, Olde B, Persson R, Thatcher M E, Sargent K. Hemodialysis blood access flow rates can be estimated accurately from on-line dialysate urea measurements and the knowledge of effective dialyzer urea clearance.  Clin J Am Soc Nephrol. 2006;  1(5) 960-964
  • 24 May R E, Himmelfarb J, Yenicesu M et al.. Predictive measures of vascular access thrombosis: a prospective study.  Kidney Int. 1997;  52(6) 1656-1662
  • 25 Sands J, Glidden D, Miranda C. Hemodialysis access flow measurement. Comparison of ultrasound dilution and duplex ultrasonography.  ASAIO J. 1996;  42(5) M899-M901
  • 26 Huisman R M, van Dijk M, de Bruin C et al.. Within-session and between-session variability of haemodialysis shunt flow measurements.  Nephrol Dial Transplant. 2005;  20(12) 2842-2847
  • 27 Lacson Jr E, Lazarus J M, Panlilio R, Gotch F. Comparison of hemodialysis blood access flow rates using online measurement of conductivity dialysance and ultrasound dilution.  Am J Kidney Dis. 2008;  51(1) 99-106
  • 28 Lopot F, Nejedlý B, Sulková S, Bláha J. Comparison of different techniques of hemodialysis vascular access flow evaluation.  J Vasc Access. 2004;  5(1) 25-32
  • 29 Schneditz D, Bachler I, van der Sande F M. Timing and reproducibility of access flow measurements using extracorporeal temperature gradients.  ASAIO J. 2007;  53(4) 469-473
  • 30 Tonelli M, Klarenbach S, Jindal K et al.. Access flow in arteriovenous accesses by optodilutional and ultrasound dilution methods.  Am J Kidney Dis. 2005;  46(5) 933-937
  • 31 Wijnen E, Essers S, van Meijel G et al.. Comparison between two on-line reversed line position hemodialysis vascular access flow measurement techniques: saline dilution and thermodilution.  ASAIO J. 2006;  52(4) 410-415
  • 32 Depairon M, Ferrier C P, Tutta P, Descombes E, van Melle G, Wauters J P. Is there a place for duplex screening of brachial artery in haemodialysis patients with vascular access?.  Vasa. 2001;  30(1) 53-58
  • 33 Lomonte C, Casucci F, Antonelli M et al.. Is there a place for duplex screening of the brachial artery in the maturation of arteriovenous fistulas?.  Semin Dial. 2005;  18(3) 243-246
  • 34 Wiese P, Blume J, Mueller H J, Renner H, Nonnast-Daniel A B. Clinical and Doppler ultrasonography data of a polyurethane vascular access graft for haemodialysis: a prospective study.  Nephrol Dial Transplant. 2003;  18(7) 1397-1400
  • 35 Perazella M A, Rodby R A. Gadolinium-induced nephrogenic systemic fibrosis in patients with kidney disease.  Am J Med. 2007;  120(7) 561-562
  • 36 Schwab S J, Raymond J R, Saeed M, Newman G E, Dennis P A, Bollinger R R. Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses.  Kidney Int. 1989;  36(4) 707-711
  • 37 Besarab A, Sullivan K L, Ross R P, Moritz M J. Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis.  Kidney Int. 1995;  47(5) 1364-1373
  • 38 White J J, Jones S A, Ram S J, Schwab S J, Paulson W D. Mathematical model demonstrates influence of luminal diameters on venous pressure surveillance.  Clin J Am Soc Nephrol. 2007;  2(4) 681-687
  • 39 Frinak S, Zasuwa G, Dunfee T, Besarab A, Yee J. Dynamic venous access pressure ratio test for hemodialysis access monitoring.  Am J Kidney Dis. 2002;  40(4) 760-768
  • 40 Duijm L E, Liem Y S, van der Rijt R H et al.. Inflow stenoses in dysfunctional hemodialysis access fistulae and grafts.  Am J Kidney Dis. 2006;  48(1) 98-105
  • 41 Beathard G A. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis.  Kidney Int. 1992;  42(6) 1390-1397
  • 42 Schwab S J, Saeed M, Sussman S K, McCann R L, Stickel D L. Transluminal angioplasty of venous stenoses in polytetrafluoroethylene vascular access grafts.  Kidney Int. 1987;  32(3) 395-398
  • 43 Aruny J E, Lewis C A, Cardella J F Society of Interventional Radiology Standards of Practice Committee et al. Quality improvement guidelines for percutaneous management of the thrombosed or dysfunctional dialysis access.  J Vasc Interv Radiol. 2003;  14(9 Pt 2) S247-S253
  • 44 Allon M, Bailey R, Ballard R et al.. A multidisciplinary approach to hemodialysis access: prospective evaluation.  Kidney Int. 1998;  53(2) 473-479
  • 45 Cayco A V, Abu-Alfa A K, Mahnensmith R L, Perazella M A. Reduction in arteriovenous graft impairment: results of a vascular access surveillance protocol.  Am J Kidney Dis. 1998;  32(2) 302-308
  • 46 Daniels I D, Berlyne G M, Barth R H. Blood flow rate and access recirculation in hemodialysis.  Int J Artif Organs. 1992;  15(8) 470-474
  • 47 Safa A A, Valji K, Roberts A C, Ziegler T W, Hye R J, Oglevie S B. Detection and treatment of dysfunctional hemodialysis access grafts: effect of a surveillance program on graft patency and the incidence of thrombosis.  Radiology. 1996;  199(3) 653-657
  • 48 Windus D W, Audrain J, Vanderson R, Jendrisak M D, Picus D, Delmez J A. Optimization of high-efficiency hemodialysis by detection and correction of fistula dysfunction.  Kidney Int. 1990;  38(2) 337-341
  • 49 Bay W H, Henry M L, Lazarus J M, Lew N L, Ling J, Lowrie E G. Predicting hemodialysis access failure with color flow Doppler ultrasound.  Am J Nephrol. 1998;  18(4) 296-304
  • 50 Bosman P J, Boereboom F T, Eikelboom B C, Koomans H A, Blankestijn P J. Graft flow as a predictor of thrombosis in hemodialysis grafts.  Kidney Int. 1998;  54(5) 1726-1730
  • 51 Lindsay R M, Blake P G, Malek P, Posen G, Martin B, Bradfield E. Hemodialysis access blood flow rates can be measured by a differential conductivity technique and are predictive of access clotting.  Am J Kidney Dis. 1997;  30(4) 475-482
  • 52 McCarley P, Wingard R L, Shyr Y, Pettus W, Hakim R M, Ikizler T A. Vascular access blood flow monitoring reduces access morbidity and costs.  Kidney Int. 2001;  60(3) 1164-1172
  • 53 Neyra N R, Ikizler T A, May R E et al.. Change in access blood flow over time predicts vascular access thrombosis.  Kidney Int. 1998;  54(5) 1714-1719
  • 54 Schwab S J, Oliver M J, Suhocki P, McCann R. Hemodialysis arteriovenous access: detection of stenosis and response to treatment by vascular access blood flow.  Kidney Int. 2001;  59(1) 358-362
  • 55 Singh N, Ahmad S, Wienckowski J R, Murray B M. Comparison of access blood flow and venous pressure measurements as predictors of arteriovenous graft thrombosis.  J Vasc Access. 2006;  7(2) 66-73
  • 56 Tonelli M, Klarenbach S, Jindal K et al.. Access flow in arteriovenous accesses by optodilutional and ultrasound dilution methods.  Am J Kidney Dis. 2005;  46(5) 933-937
  • 57 Asif A, Leon C, Orozco-Vargas L C et al.. Accuracy of physical examination in the detection of arteriovenous fistula stenosis.  Clin J Am Soc Nephrol. 2007;  2(6) 1191-1194
  • 58 Leon C, Orozco-Vargas L C, Krishnamurthy G et al.. Accuracy of physical examination in the detection of arteriovenous graft stenosis.  Semin Dial. 2008;  21(1) 85-88
  • 59 Leon C, Asif A. Physical examination of arteriovenous fistulae by a renal fellow: does it compare favorably to an experienced interventionalist?.  Semin Dial. 2008;  21(6) 557-560
  • 60 Lindsay R M, Blake P G, Bradfield E. Estimation of hemodialysis access blood flow rates by a urea method is a poor predictor of access outcome.  ASAIO J. 1998;  44(6) 818-822
  • 61 Dember L M, Holmberg E F, Kaufman J S. Randomized controlled trial of prophylactic repair of hemodialysis arteriovenous graft stenosis.  Kidney Int. 2004;  66(1) 390-398
  • 62 Lumsden A, MacDonald M J, Kikeri D. Prophylactic balloon angioplasty fails to prolong the patency of expanded polytetrafluoroethylene arteriovenous grafts.  J Vasc Surg. 1997;  26 382-392
  • 63 Ram S J, Work J, Caldito G C, Eason J M, Pervez A, Paulson W D. A randomized controlled trial of blood flow and stenosis surveillance of hemodialysis grafts.  Kidney Int. 2003;  64(1) 272-280
  • 64 Ram S J, Nassar R, Work J, Abreo K, Dossabhoy N R, Paulson W D. Risk of hemodialysis graft thrombosis: analysis of monthly flow surveillance.  Am J Kidney Dis. 2008;  52(5) 930-938
  • 65 Moist L M, Churchill D N, House A A et al.. Regular monitoring of access flow compared with monitoring of venous pressure fails to improve graft survival.  J Am Soc Nephrol. 2003;  14(10) 2645-2653
  • 66 Robbin M L, Oser R F, Lee J Y, Heudebert G R, Mennemeyer S T, Allon M. Randomized comparison of ultrasound surveillance and clinical monitoring on arteriovenous graft outcomes.  Kidney Int. 2006;  69(4) 730-735
  • 67 Malik J, Slavikova M, Svobodova J, Tuka V. Regular ultrasonographic screening significantly prolongs patency of PTFE grafts.  Kidney Int. 2005;  67(4) 1554-1558
  • 68 Tonelli M, Hirsch D, Clark T W et al.. Access flow monitoring of patients with native vessel arteriovenous fistulae and previous angioplasty.  J Am Soc Nephrol. 2002;  13(12) 2969-2973
  • 69 Tessitore N, Lipari G, Poli A et al.. Can blood flow surveillance and pre-emptive repair of subclinical stenosis prolong the useful life of arteriovenous fistulae? A randomized controlled study.  Nephrol Dial Transplant. 2004;  19(9) 2325-2333
  • 70 Polkinghorne K R, Lau K K, Saunder A, Atkins R C, Kerr P G. Does monthly native arteriovenous fistula blood-flow surveillance detect significant stenosis—a randomized controlled trial.  Nephrol Dial Transplant. 2006;  21(9) 2498-2506
  • 71 Sands J J, Jabyac P A, Miranda C L, Kapsick B J. Intervention based on monthly monitoring decreases hemodialysis access thrombosis.  ASAIO J. 1999;  45(3) 147-150
  • 72 Smits J H, van der Linden J, Hagen E C et al.. Graft surveillance: venous pressure, access flow, or the combination?.  Kidney Int. 2001;  59(4) 1551-1558
  • 73 Tonelli M, James M, Wiebe N, Jindal K, Hemmelgarn B. Alberta Kidney Disease Network . Ultrasound monitoring to detect access stenosis in hemodialysis patients: a systematic review.  Am J Kidney Dis. 2008;  51(4) 630-640
  • 74 Allon M. Do we really need periodic monitoring of vascular access for hemodialysis?.  NephSAP. 2007;  6 111-116
  • 75 Besarab A. Access monitoring is worthwhile and valuable.  Blood Purif. 2006;  24(1) 77-89
  • 76 Paulson W D. Access monitoring does not really improve outcomes.  Blood Purif. 2005;  23(1) 50-56
  • 77 Sands J J. Vascular access monitoring improves outcomes.  Blood Purif. 2005;  23(1) 45-49
  • 78 White J J, Bander S J, Schwab S J et al.. Is percutaneous transluminal angioplasty an effective intervention for arteriovenous graft stenosis?.  Semin Dial. 2005;  18(3) 190-202
  • 79 Wijnen E, Planken N, Keuter X et al.. Impact of a quality improvement programme based on vascular access flow monitoring on costs, access occlusion and access failure.  Nephrol Dial Transplant. 2006;  21(12) 3514-3519

William L WhittierM.D. 

Department of Internal Medicine, Division of Nephrology, Rush University Medical Center

1426 W. Washington Blvd., Chicago, IL 60607