https://www.youtube.com/watch?

v=2m8T77f7-S0

AV FISTULA EXAMINATION

 Inspection
o Exposure – sleeveless
o Examine entire hand on area with fistula an draining veins all the way to central veins.
o General comments: Patient stable in no obvious distress
o Compare with other arm
o There are 2 swellings (aneurysms) – on inferior aspect of forearm etc etc. Size, site,
surface, mobility etc consistent with an AV fistula
o Veins
 accessory & collateral visible
 stenosis – bluish/purplish veins
o Scars
o Skin changes on access site
 Inflammation signs: Erythema, rash, swelling
 Infection: Drainage/Discharge, Abscess
 Active bleeding
 Thinning of skin overlying fistula
o Hands
 Infection - warmth
 assess for vascular steal syndrome (esp with fistula at elbow)
 Ischemia
 Numbness
 Cold extremity
 Ulceration
 Pain
 discolouration
o
 Palpation
o From anastomosis to supraclavicular area and drainage area on chest for pulsations
o Use palmar aspect of hand or 3 to 4 fingers
o Pulses
 In the body there should be little or pulse
 If you press down too hard, you can induce an obstruction therefore feel lightly
 No pulse – normal. If there is a pulse it implies downstream resistance
 Thrill – normal - flow is good
o Thrill
 Present: rate the thrill. Should decrease as you move further away from fistula
site
o Brisk, strong
 o Weak, slow

 Absent – failure of fistula

 Phase its felt – systolic or diastolic. Normal thrill is continuous and heard in both
systole and diastole. With stenosis, diastolic thrill disappears
o Special Tests
 Augmentation (assesses anastomotic stenosis)
 Occlude vein 1-2cm above anastomosis , if there is no anastomotic
stenosis, a pulsation in the vein will be seen due to conduction of
arterial pressure into the vein. N.B if vein is pulsatile without occlusion
then there is venous outflow stenosis.
 Most proximal bump – anastomosis site
 Between anastomotic site and second bump – flat area called
juxtaanastomotic site
 Rest beyond is the body
 Anastomosis – area of loudest intensity/maximum thrill
 Juxta-anastomotic site: common region for pathology (stenosis)
 Occlude totally area just behind proximal bump with 1 finger and feel
on both bumps.
 If it augments well finger resting on bumps rises and falls (strong pulse)
therefore there is no stenosis
 Feel for thrill while occluded too – normal is no thrill
 Arm elevation (outflow obstruction)
 Ask patient to hold access arm down and make a fist
 With hand fisted, ask patient to raise their arm above their head
 Veins should collapse when raised and refill when horizontal if there is
no stenosis
 With stenosis, fistula acts like a dam, backs up blood into distended
area. Part of fistula therefore will engorge and the other part will stay
flat. If there is central vein stenosis, the entire fistula stays engorged.
 Area distal to stenosis distends
 Proximal to stenosis - collapse

o Accessory vein test
 Start occluding in juxta-anastomotic site and feel for thrill
 Move short distance – if thrill felt there could be an accessory pathway (normal
variant) or a collateral pathway (pathological).
 See if the accessory or collateral veins are visible
  Auscultation
o Bruit goes along with thrill
o Focus on diastolic component, if present, there is no stenosis
o Pitch of sound – normal is continuous machinery like with low pitch
o Stenosis – high pitched sound discontinuous, whistling, louder at site of stenosis an
anastomoses

QUESTIONS

1. What is an AV fistula
 Surgically created anastomosis between an artery an a vein. The main use is to dilate a
vein so that it can be used for performing regular haemodialysis

2. Why is it needed
 Blood volume that needs to be removed and returned during haemodialysis is too great
for a normal vein to cope with. Joining an artery and a vein allows the higher arterial
pressure to be transmitted to the vein causing:
o Dilatation
o Thickening of walls
o Increased blood flow through the vein
 Once the vein is sufficiently dilated (matured), it is ready for dialysis

3. Special instructions to the patient

 Do not allow anyone to:
o Take blood from the arm
o Cannulate the arm
o Take BP measurements from the arm
 If you notice active bleeding, loss of thrill and infection visit nearest health facility
4. Alternative methods of performing haemodialysis
 Peritoneal haemodialysis
 Central venous catheter

5. Advantages of an AV fistula
 Lower infection rate than a Central venous catheter
 Higher blood flow rate
 Lower thrombosis incidence

6. Complications of AV fistula
 Thrombosis
 Infection – Staph aureus most common (patient, hospital staff), therefore hand hygiene
 Aneurysm
 Vascular steal syndrome – common in diabetics and people with elbow fistulae
 Stenosis (venous)