A palpable “thrill” is traditionally associated with success following arteriovenous fistula (AVF) surgery. A thrill typically characterizes turbulent flow and this is a paradox as turbulence is a driver of neointimal hyperplasia. Spiral laminar flow (SLF) has been described as normal and protective pattern of flow in native arteries and is associated with superior patency in bypass grafts that generate it. The aim of this study was to define the pattern of flow within AVFs immediately post-operatively and at follow-up to assess maturation.
Methods
Doppler ultrasound was used immediately post-operatively and at follow-up (6 weeks). Blood flow was assessed as SLF or non-SLF. Two blinded qualified observers analysed the images. Patients were followed up for 6 months. Maturation was statistically analysed against the type of flow.
Results
Sequential patients having AVF surgery (n=56) were assessed: 46 (82%) patients had a thrill, 3 patients had no flow and 7 patients had pulsatile flow without a palpable thrill. SLF was present in 80% of those with a thrill but not in any without a thrill (p<0.0001). At follow-up (n=51) 41, patients had a matured AVF (80%), of which 76% had SLF immediately post-operatively. Only one patient with SLF failed to mature. In the non-SLF group 5 of the 15 AVFs failed to mature (66%; p<0.005).
Conclusions
SLF was strongly supportive of successful fistula maturation. A “thrill” was characteristic of spiral rather than turbulence. The mechanism of this apparent beneficial effect of this pattern of flow requires further investigation.
LehouxS., CastierY., TedguiA.. Molecular mechanisms of the vascular responses to haemodynamic forces.J Intern Med.2006; 259(4): 381–392.
2.
KangL., YamadaS., HernandezM.C.. Regional and systemic hemodynamic responses following the creation of a murine arteriovenous fistula.Am J Physiol Renal Physiol.2011; 301(4): F845–F851.
3.
Ene-IordacheB., CattaneoL., DubiniG., RemuzziA.. Effect of anastomosis angle on the localization of disturbed flow in “side-to-end” fistulae for haemodialysis access.Nephrol Dial Transplant.2013; 28(4): 997–1005.
4.
BaderoO.J., SalifuM.O., WasseH., WorkJ.. Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions.Am J Kidney Dis.2008; 51(1): 93–98.
5.
FalkA., TeodorescuV., LouW.Y., UribarriJ., VassalottiJ.A.. Treatment of “swing point stenoses” in hemodialysis arteriovenous fistulae.Clin Nephrol.2003; 60(1): 35–41.
6.
Beathard GA, Arnold P, Jackson J, Litchfield T; Physician Operators Forum of RMS Lifeline.Aggressive treatment of early fistula failure.Kidney Int.2003; 64(4): 1487–1494.
7.
Roy-ChaudhuryP., SukhatmeV.P., CheungA.K.. Hemodialysis vascular access dysfunction: a cellular and molecular viewpoint.J Am Soc Nephrol.2006; 17(4): 1112–1127.
8.
DiskinC.J., StokesT.J., DansbyL.M., RadcliffL., CarterT.B.. Understanding the pathophysiology of hemodialysis access problems as a prelude to developing innovative therapies.Nat Clin Pract Nephrol.2008; 4(11): 628–638.
9.
Roy-ChaudhuryP., ZhangJ., KrishnamoorthyM.. Cellular phenotypes in dialysis access stenosis: myofibroblasts, fibroblasts and contractile smooth muscle cells.J Am Soc Nephrol.2006; 17: 75A.
10.
StrackeS., KonnerK., KöstlinI.. Increased expression of TGF-beta1 and IGF-I in inflammatory stenotic lesions of hemodialysis fistulas.Kidney Int.2002; 61(3): 1011–1019.
11.
HoustonJ.G., GandyS.J., MilneW., DickJ.B., BelchJ.J., StonebridgeP.A.. Spiral laminar flow in the abdominal aorta: a predictor of renal impairment deterioration in patients with renal artery stenosis?Nephrol Dial Transplant.2004; 19(7): 1786–1791.
12.
Monroy-CuadrosM., YilmazS., Salazar-BañuelosA., DoigC.. Independent prediction factors for primary patency loss in arteriovenous grafts within six months.J Vasc Access.2012; 13(1): 29–35.
13.
JemcovT.K.. Morphologic and functional vessels characteristics assessed by ultrasonography for prediction of radiocephalic fistula maturation.J Vasc Access.2013; 14(4): 356–363.
KokkalisE., HoskinsP.R., CornerG.A.. Secondary flow in peripheral vascular prosthetic grafts using vector Doppler imaging.Ultrasound Med Biol.2013; 39(12): 2295–2307.
18.
HeerwagenS.T., LönnL., SchroederT.V., LadefogedS.D., HansenM.A.. Catheter-based flow measurements in hemodialysis fistulas—bench testing and clinical performance.J Vasc Access.2012; 13(1): 45–50.
19.
StonebridgeP.A., BrophyC.M.. Spiral laminar flow in arteries?Lancet.1991; 338(8779): 1360–1361.
20.
StonebridgeP.A., BuckleyC., ThompsonA.. Non spiral and spiral (helical) flow patterns in stenoses. In vitro observations using spin and gradient echo magnetic resonance imaging (MRI) and computational fluid dynamic modeling.Int Angiol.2004; 23(3): 276–283.
21.
JahromeO.K., HoeferI., HoustonG.J.. Hemodynamic effects of spiral ePTFE prosthesis compared with standard arteriovenous graft in a carotid to jugular vein porcine model.J Vasc Access.2011; 12(3): 224–230.
GimbroneM.A.Jr., TopperJ.N., NagelT., AndersonK.R., Garcia-CardeñaG.. Endothelial dysfunction, hemodynamic forces, and atherogenesis.Ann N Y Acad Sci.2000; 902(1): 230–239, discussion 239-240.
24.
KrishnamoorthyM.K., BanerjeeR.K., WangY.. Hemodynamic wall shear stress profiles influence the magnitude and pattern of stenosis in a pig AV fistula.Kidney Int.2008; 74(11): 1410–1419.
25.
MartinD., ZamanA., HackerJ., MendelowD., BirchallD.. Analysis of haemodynamic factors involved in carotid atherosclerosis using computational fluid dynamics.Br J Radiol.2009; 82(Special Issue 1)(Spec No 1): S33–S38.
26.
HoustonJ.G., GandyS.J., SheppardD.G., DickJ.B., BelchJ.J., StonebridgeP.A.. Two-dimensional flow quantitative MRI of aortic arch blood flow patterns: effect of age, sex, and presence of carotid atheromatous disease on prevalence of spiral blood flow.J Magn Reson Imaging.2003; 18(2): 169–174.
