Diagnostic Radiology
Venous Angiography of Hemodialysis Fistulas Experience with 52 Studies 1 Louis A. Gilula, M.D., Tom W. Staple, M.D., 2 Charles B. Anderson, M.D., and Larry S. Anderson, M.D. The authors describe a simple outpatient venous angiographic method of delineating arteriovenous fistulas constructed for chronic hemodialysis, and variations of the basic technique are offered to solve the problems of overlapping vessels and obscured anastomoses. A normal fistula produces enlargement of the involved artery only, but there may be enlargement of multiple veins in the extremity in which the fistula is constructed. Stenoses, occlusions, surgical variations, aneurysms, functional abnormalities in the direction and quantity of flow, and inadequate positioning of the dialysis needles are discussed. INDEX TERMS:
Blood, flow dynamics. Hemodialysis • Malformations, arteriovenous
Radiology 115: 555-562, .June 1975
1973, one of us (T.W.S.) described a simple outpatient angiographic method of delineating arteriovenous fistulas constructed to facilitate chronic hemodialysis (6). Since then, we have performed 52 examinations on 50 patients referred from the Chromalloy American Kidney Center of Washington University. There are approximately 13,000 patients with end-stage renal disease in the United States who are presently undergoing such treatment (5), and with governmental financial aid now available this number will probably double. Likewise the number of complications attendant upon the use of dialysis fistulas will increase. For these reasons, we wish to describe our experience with angiographic analysis of such arteriovenous fistulas. Hemodialysis is accomplished by percutaneous cannulation of the venous limb of an arteriovenous fistula which has been created surgically near the wrist between the radial artery and the cephalic vein (2). Blood from the resultant enlarged vein proximal to the fistula is delivered to the hemodialysis bath under arterial pressure (Fig. 1). The dialyzed blood is returned via a second needle inserted into the same or another vein located proximal to the first needle; alternatively, a unipuncture needle with a valve allowing both withdrawal and injection of blood through the same needle may be employed. Satisfactory hemodialysis requires three 6-hour sessions per week at a minimal flow rate of 200-300 ml per minute and an ideal fistula flow of 400-500 ml per minute. The distal forearm is the most practical site for fistula creation. A fistula matures in about 10 days; however, it takes three weeks for the vein to become "arterialized," i.e., large and thick enough to permit repeated dialysis. During maturation, the overlying skin heals; a thrill develops in the veins continuous with the shunt,
I
N
I
_~~~_ VENOUS
---
FROM BATH _ARTERIAL TO BATH
STENOSES - 'ARTERIAL FLOW , - - - - . I. VENOUS STENOSIS
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Venous Angiography of Hemodialysis Fistulas Experience with 52 Studies 1 Louis A. Gilula, M.D., Tom W. Staple, M.D., 2 Charles B. Anderson, M.D., and Larry S. Anderson, M.D. The authors describe a simple outpatient venous angiographic method of delineating arteriovenous fistulas constructed for chronic hemodialysis, and variations of the basic technique are offered to solve the problems of overlapping vessels and obscured anastomoses. A normal fistula produces enlargement of the involved artery only, but there may be enlargement of multiple veins in the extremity in which the fistula is constructed. Stenoses, occlusions, surgical variations, aneurysms, functional abnormalities in the direction and quantity of flow, and inadequate positioning of the dialysis needles are discussed. INDEX TERMS:
Blood, flow dynamics. Hemodialysis • Malformations, arteriovenous
Radiology 115: 555-562, .June 1975
1973, one of us (T.W.S.) described a simple outpatient angiographic method of delineating arteriovenous fistulas constructed to facilitate chronic hemodialysis (6). Since then, we have performed 52 examinations on 50 patients referred from the Chromalloy American Kidney Center of Washington University. There are approximately 13,000 patients with end-stage renal disease in the United States who are presently undergoing such treatment (5), and with governmental financial aid now available this number will probably double. Likewise the number of complications attendant upon the use of dialysis fistulas will increase. For these reasons, we wish to describe our experience with angiographic analysis of such arteriovenous fistulas. Hemodialysis is accomplished by percutaneous cannulation of the venous limb of an arteriovenous fistula which has been created surgically near the wrist between the radial artery and the cephalic vein (2). Blood from the resultant enlarged vein proximal to the fistula is delivered to the hemodialysis bath under arterial pressure (Fig. 1). The dialyzed blood is returned via a second needle inserted into the same or another vein located proximal to the first needle; alternatively, a unipuncture needle with a valve allowing both withdrawal and injection of blood through the same needle may be employed. Satisfactory hemodialysis requires three 6-hour sessions per week at a minimal flow rate of 200-300 ml per minute and an ideal fistula flow of 400-500 ml per minute. The distal forearm is the most practical site for fistula creation. A fistula matures in about 10 days; however, it takes three weeks for the vein to become "arterialized," i.e., large and thick enough to permit repeated dialysis. During maturation, the overlying skin heals; a thrill develops in the veins continuous with the shunt,
I
N
I
_~~~_ VENOUS
---
FROM BATH _ARTERIAL TO BATH
STENOSES - 'ARTERIAL FLOW , - - - - . I. VENOUS STENOSIS
"
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