1. The Role of the Technologist in Pre-Op Surgical Planning for AVF/AVG
David Lorelli, MD, RVT, FACS
Medical Director Vascular Lab
St John Hospital and Medical Center
Detroit, Michigan

2. Table of Contents Upper Extremity Anatomy
Basics of an Arteriovenous Fistula
Arteriovenous Graft (AVG)
Access Performance
Upper Extremity Duplex
Information for the Physician
Vein Mapping
Limitations
Helpful Scanning Techniques

3. Upper Extremity Anatomy
Deep Veins
- Jugular
- Subclavian
- Axillary
- Brachial
- Radial
- Ulnar
Superficial Veins
- Cephalic
- Basilic
- Medial cubital vein 3

4. What is an Arteriovenous Fistula (AVF)
Patients who are in kidney failure need hemodialysis to supplement their kidney function.
An arteriovenous fistula is the connection of a vein and an artery to allow access to the vascular system for hemodialysis.
The surgical creation of an AVF provides a long-lasting site through which blood can be removed and returned to the body during a hemodialysis treatment.
The fistula, which allows the person to be connected to a dialysis machine, must be prepared by a surgeon weeks or months before dialysis is started.
It takes approximatley 4-12 weeks for an AVF to fully mature.

5. Basics of an Arteriovenous Fistula
The venous system contains Deep and Superficial veins. The Superficial system is most important for AVF creation.
Cephalic vein is most commonly utilized.
- radiocephalic and brachiocephalic
All Cephalic options are considered before the proximal Basilic vein.
Basilic vein is second choice because it lies beneath the deep fascia and must be brought more superficial. This is known as a Transposed Basilic vein AVF.
Brachial veins can also be used for access.

9. Arteriovenous Graft (AVG)
If all native vessels are not suitable for creating an AVF then a graft made of synthetic material is utilized.
Common material is Polytetrafluoroethylene (PTFE)
Types of loops include: Forearm loop, upper arm straight or loop, and thigh loop.

11. Access Performance
Rate of blood flow varies depending on the anatomy of the access:
AVF with radial artery ml/min
AVF with brachial artery ml/min
AVG ml/min

12. Factors Affecting Blood Flow Rates
Performance of the blood pump (heart)
Blood pressure, ejection fraction, cardiac rhythm
Cardiac output also affected by
Fluid volume status, BP medications, cardiac disease
Atherosclerosis causing flow limiting stenosis

13. Blood Flow Rates
Any factor which decreases the rate of intra access blood flow can lead to suboptimal hemodialysis treatments and may eventually increase patient morbidity and mortality.

14. Upper Extremity Duplex
An ultrasound is done to determine the patency, size and condition of the veins.
Generally a full evaluation of the venous system is completed to rule out DVT.
Diameter measurements are taken of the superficial veins .
- Proximal, mid, distal upper and lower Cephalic.
-Proximal, mid, distal upper and lower Basilic.
- If visualized, measure the medial cubital vein.
Depending on the physician, diameter measurements are taken of specific arteries.
Diameter measurement of the Cephalic Vein.

15. Information for the Physician
Dominant arm of the patient
Any branches that come off the superficial veins
Any dilations in the veins
Thickening of the vessel walls
If DVT or SVT is visualized
Any areas of stenosis.
Any limitations

16. Information for the Physician
Once the duplex is finished, the physician makes the decision of which fistula or graft is best for the patient.
2-2.5 mm and above are acceptable diameter measurements for a fistula.
The non-dominant hand is preferable.

17. Vein Mapping
The day of the surgery the technologist needs to mark the exact location and where the vein courses down the arm.
With a permanent marker, the tech keeps the vein in the middle of the screen and writes on the patients arm at the center of the probe to ensure the right area is being mapped.
Follow the vein as far proximal and distal as possible.
Also mark any branches that might be coming off the vein.
The physician may also need to know how far the vein is from the skin. Measure from the top of the vein to the top of the screen.

18. Limitations Obese patients with deep vessels
A cast that limits the scanning area
Trauma or open wounds
Severe edema
Central venous line or dialysis access

19. Helpful Scanning Techniques
If the vein is very superficial and the weight of the probe is collapsing the vein, stabilize your hand on the patients arm to release some pressure from the probe.
Switch to a higher frequency probe to visualize the superficial veins better.
When mapping for surgery, a tourniquet can be used to better visualize the veins.
Do not leave the tourniquet on for too long or have it too tight, just enough to help the veins be more visible.

20. New Alternatives HeRO catheter/graft
Allows upper extremity access even with peripheral venous outflow obstruction.

21. The HeRO Graft (Hemodialysis Reliable Outflow)
HeRO Graft is the only fully subcutaneous AV access solution clinically proven to maintain long-term access for catheter-dependent patients with central venous stenosis.
HeRO bypasses central
venous stenosis 21 21

22. New Alternatives TEVG (Tissue Engineered Vascular Graft)
Built to tolerate hemodynamic loads, heal and remodel in response to needle sticks, resist infection, no post op maturation period. Currently the major draw back is cost effectiveness.

23. References
ACR–AIUM–SRU Practice Guideline for the Performance of Peripheral Venous Ultrasound Examination American College of Radiology.
Atlas of Dialysis Vascular Access. Tushar J. Vacharajani
Mayo Foundation for Medical Education and Research (MFMER).March
Upper Extremity Venous Duplex Evaluation R/O Deep/Superficial Vein Thrombosis. Society for Vascular Ultrasound. January Duplex_Eval_2010.pdf
Vascular Access to Hemodialysis. National Kidney and Urologic Disease Information Clearinghouse, Home Health Information. December 23

24. Questions