Difficult cannulation of hemodialysis arteriovenous fistula – Role of imaging in access management (DICAF STUDY)

Abstract

Background:

Difficulty in cannulation of arteriovenous fistula (AVF) can lead to inadequate dialysis, transient to permanent loss of access and increases dependency on bridging catheters. This study aimed to analyze the causes for difficult fistula cannulation, using various imaging modalities.

Methodology:

This was a retrospective single-center observational study conducted between October 2017 and June 2018. Patients whose fistulae were difficult to cannulate were initially evaluated by physical examination followed by doppler ultrasonography or/and fistulogram as necessary. The patients were divided into two groups that is, primary difficult cannulation (within first three months of creation of fistula) or secondary difficult cannulation (after three months).

Results:

We encountered difficult cannulation in 43 patients. About 60% were primary difficult cannulations. Most common causes for difficulty in cannulation were cannulation zone (CZ) stenosis (23.3%), immature fistula (20.9%), outflow stenosis (18.6%), inflow stenosis (11.6%), anatomical abnormalities (11.6%), outflow plus CZ stenosis (9.3%) and inflow plus CZ stenosis (4.7%). Among patients with primary difficult cannulation, immature fistula (34.6%) was the most common cause, whereas CZ stenosis (47.1%) was the most common etiology for secondary difficult cannulation. Edema leading to difficult cannulation was found in 12 patients (27.9%), all of which was due to central vein stenosis. Cannulation resulted in hematoma, fistula thrombosis, failure of fistula and pseudoaneurysm in 83.7%, 27.9%, 16.3%, and 2.3% of cases respectively. Bridging temporary dialysis catheter placement was required in 67.4% patients. Ultrasound doppler had lower diagnostic value when compared to fistulogram (71.4% vs 93.9%, p = 0.014).

Conclusion:

Difficulty in cannulating the arteriovenous fistula is a common problem in hemodialysis patients. We suggest that patients whose fistulae are difficult to cannulate should undergo early radiological evaluation to decrease catheter dependency and access failure.

Keywords

Difficult cannulation unsuccessful cannulation arterio-venous fistula immature fistula stenosis

Get full access to this article

View all access options for this article.

References

Lok

. Fistula first initiative: advantages and pitfalls. Clin J Am Soc Nephrol 2007; 2: 1043–1053.

Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48(Suppl. 1): S176–S247.

Lok

Huber

Lee

, et al. KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis 2020; 75: S1–S164.

Fluck

Kumwenda

. Renal association clinical practice guideline on vascular access for haemodialysis. Nephron Clin Pract 2011; 118(Suppl. 1): c225–c240.

Coventry

Hosking

Chan

, et al. Variables associated with successful vascular access cannulation in hemodialysis patients: a prospective cohort study. BMC Nephrol 2019; 20: 197.

van Loon

Kessels

AGH

Van der Sande

, et al. Cannulation and vascular access-related complications in hemodialysis: factors determining successful cannulation. Hemodial Int Int Symp Home Hemodial 2009; 13: 498–504.

Fitzgerald

Schanzer

Chin

, et al. Outcomes of upper arm arteriovenous fistulas for maintenance hemodialysis access. Arch Surg 2004; 139: 201–208.

Patel

Hughes

Mills

. Failure of arteriovenous fistula maturation: an unintended consequence of exceeding dialysis outcome quality Initiative guidelines for hemodialysis access. J Vasc Surg 2003; 38: 439–445; discussion 445.

Lok

Allon

Moist

, et al. Risk Equation Determining Unsuccessful Cannulation Events and Failure to Maturation in Arteriovenous Fistulas (REDUCE FTM I). J Am Soc Nephrol 2006; 17: 3204–3212.

10.

Badero

Salifu

Wasse

, et al. Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions. Am J Kidney Dis 2008; 51: 93–98.

11.

Beathard

Arnold

Jackson

, et al. Aggressive treatment of early fistula failure. Kidney Int 2003; 64: 1487–1494.

12.

Asif

Gadalean

Merrill

, et al. Inflow stenosis in arteriovenous fistulas and grafts: a multicenter, prospective study. Kidney Int 2005; 67: 1986–1992.

13.

Mickley

. Stenosis and thrombosis in haemodialysis fistulae and grafts: the surgeon’s point of view. Nephrol Dial Transplant 2004; 19: 309–311.

14.

Stolic

. Most important chronic complications of arteriovenous fistulas for hemodialysis. Med Princ Pract 2013; 22: 220–228.

15.

MacRae

Dipchand

Oliver

, et al. Arteriovenous access failure, stenosis, and thrombosis. Can J Kidney Health Dis 2016; 3: 2054358116669126.

16.

Wilmink

Hollingworth

Powers

, et al. Natural history of common autologous arteriovenous fistulae: consequences for planning of dialysis access. Eur J Vasc Endovasc Surg 2016; 51: 134–140.

17.

Masengu

Maxwell

Hanko

. Investigating clinical predictors of arteriovenous fistula functional patency in a European cohort. Clin Kidney J 2016; 9: 142–147.

18.

Haq

Althaf

Lee

. Accessory vein obliteration for early fistula failure: a myth or reality? Adv Chronic Kidney Dis 2015; 22: 438–445.

19.

Dixon

. Why don’t fistulas mature? Kidney Int 2006; 70: 1413–1422.

20.

Asif

Roy-Chaudhury

Beathard

. Early arteriovenous fistula failure: a logical proposal for when and how to intervene. Clin J Am Soc Nephrol 2006; 1: 332–339.

21.

Ravani

Brunori

Mandolfo

, et al. Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study. J Am Soc Nephrol 2004; 15: 204–209.

22.

Lomonte

Basile

. Preoperative assessment and planning of haemodialysis vascular access. Clin Kidney J 2015; 8: 278–281.

23.

Tawfiq Korim

Ferring

Henderson

, et al. Venous hypertension in the hand and forearm after brachioaxillary graft formation. EJVES Extra 2007; 13: 92–94.

24.

Al-Jaishi

Liu

Lok

, et al. Complications of the arteriovenous fistula: a systematic review. J Am Soc Nephrol 2017; 28: 1839–1850.

25.

Hossny

. Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysis-related complications. J Vasc Surg 2003; 37: 821–826.

26.

Coentrão

Santos-Araújo

Dias

, et al. Effects of starting hemodialysis with an arteriovenous fistula or central venous catheter compared with peritoneal dialysis: a retrospective cohort study. BMC Nephrol 2012; 13: 88.

27.

Bream

. Update on insertion and complications of central venous catheters for hemodialysis. Semin Interv Radiol 2016; 33: 31–38.