Preoperative evaluation for vascular access creation.

In an effort to increase the prevalence of arteriovenous fistulae (AVF), ultrasound vessel mapping (USVM) and upper extremity venography (UEV) have been suggested; however, the effectiveness of their combined use remains unknown. We studied the effect of such a combined protocol on arteriovenous (AV) access type change compared with physical examination alone. Consecutive patients with chronic kidney disease (n = 137) after an initial estimation of the AV access type, based on physical examination, had USVM and UEV to detect vascular pathology that could potentially alter the original plan. USVM changed the preoperative plan in 31 (22.6%) patients; this was 36.7% (n = 18) in diabetics compared with 14.8% (n = 13) in nondiabetics (p < .001). Patients for whom USVM changed the type of planned AV access had been on hemodialysis significantly longer (2.7 years vs 0.9 years; p < .001). Venography identified 18 patients with central vein stenosis that led to a site change in 12 of them. Significant venous stenosis in patients with a history of two or more central catheters placed and patients without such a history was 93% and 1%, respectively. In eight patients, intraoperative findings dictated AV graft placement or creation of a central AVF. The original plan was revised in 31%, and this rate was similar for distal AVF, central AVF, and AV grafts (38%, 26%, and 43%, respectively; all p > .05). The 30-day patency rate was 92.2%. A significant proportion of patients have vascular pathology severe enough to alter the access type as suggested by physical examination alone. USVM should be routinely performed, whereas UEV should be selectively performed in patients with a history of surgery or instrumentation of their central veins.