Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, Use, and Examination - Dr.Gawad

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1. Mohammed Abdel Gawad MD/PhD Neph, ESENeph
Nephrology Unit, School of Medicine, NewGiza University
Nephrology Consultant, Alexandria
Founder of NephroTube.com
Chair of AFRAN Web/Media Committee
ISN Education SoMe Team Member
Chapter 9
Arteriovenous Fistula and
Graft:
Basics, Creation, Use, and
Examination
You can get this book free from www.NephroTube.com

2. Watch the video recording of this lecture
on NephroTube YouTube channel
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3. Visit
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(pdf and video recordings)

4. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

5. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

6. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

7. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

8. Vessel preservation for AVF creation
•Venipuncture:
•Not from the non-dominant arm.
•The most distal small veins.
•Highly experienced individual should operate on them.
•Use of venous catheters for dialysis:
•Better avoided.
•Refer early for AVF creation.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

9. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

10. When should AVF be created?
•GFR below 30 mL/min per 1.73 m2: comprehensive education
regarding all available KRT.
•GFR is <15–20 ml/min per 1.73 m2 or risk of KRT is >40% over 2 years:
planning for dialysis access (KDIGO CKD 2024).
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

12. When should AVF be created?
•GFR below 30 mL/min per 1.73 m2: comprehensive education
regarding all available KRT.
•GFR is <15–20 ml/min per 1.73 m2 or risk of KRT is >40% over 2 years:
planning for dialysis access (KDIGO CKD 2024).
•Earlier referral should occur in patients with unstable and/or rapid
rates of eGFR decline (e.g., >10 mL/min/year).
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

13. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

14. AVF preoperative evaluation:
Patient history
•Previous vascular intervention or surgery.
•Comorbidities.
•History of previous failed AVF and the cause of failure.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

15. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

16. AVF preoperative evaluation:
Preoperative physical examination
•Pulses
•Blood pressure
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

17. AVF preoperative evaluation:
Preoperative physical examination
•Pulses
•Blood pressure
•Allen test (test of palmar arch patency)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
https://thoracickey.com/radial-anatomy-and-pre-operative-evaluation/

18. AVF preoperative evaluation:
Preoperative physical examination
•Pulses
•Blood pressure
•Allen test (test of palmar arch patency)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
J Otolaryngol Head Neck Surg. 2015 Nov

19. AVF preoperative evaluation:
Preoperative physical examination
•Pulses
•Blood pressure
•Allen test (test of palmar arch patency)
•Examine for the evidence of heart failure
•Examine neck, chest, and upper limbs
•Evidence of infection
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

20. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

21. AVF preoperative evaluation:
Preoperative imaging
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Doppler
ultrasonography
(inadequate
visualization of
central vessels)
Minimal
vein and
artery size
•Minimum lumen diameter of 2.5 mm in the vein and 2 mm in the artery
•KDOQI Vascular Access Guideline (2019 Update): no minimum-diameter:
arteries and veins of <2 mm in diameter should undergo careful
evaluation for feasibility y to create AVF
Mapping Assess both the ulnar and cephalic veins for: Depth, Continuity, Strictures.
Venography •To assess central veins
•Use the smallest volume of iodinated contrast or non-iodinated contrast agents (e.g.,
CO2 gas)
Arteriography•When pulses are significantly diminished or absent or when there is a difference in
mean arterial pressure of more than 20 mmHg between the two limbs.
•Use the smallest volume of iodinated contrast or non-iodinated contrast agents (e.g.,
CO2 gas)

22. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

23. Conventional, transposed, and translocation
fistula
•Conventional AVF: Anastomosis is created between a superficial
artery and vein.
•Transposed AVF: Deep vein is moved into a subcutaneous tunnel and
anastomosed with an artery.
•Vein translocation AVF: A vein is surgically extracted from its
anatomical site in order to establish a connection between an artery
and another vein
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

24. AVF possible locations
•Nondominant arm.
•Distally in the upper limb.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

25. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Figure 9.1. Most commonly created AVF sites
Brachial artery
Basilic vein
Upper arm
cephalic vein
Forearm
cephalic vein
Radial artery
Ulnar artery
Wrist radiocephalic AVF
The first preferred choice
Arm brachiocephalic AVF
Transposed brachiobasilic
AVF
It is the last choice

26. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

27. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Side-to-side
anastomosis
Figure 9.2. Techniques of
anastomosis
Side-to-end
anastomosis
AVF: Techniques of anastomosis
Figure 9.2. Techniques of anastomosis

28. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

29. ERBP (2019): Perioperative prophylactic
antibiotics for preventing AVF infection
•They suggest giving preoperative antibiotic prophylaxis for complex
AVF procedures.
•They suggest not giving preoperative antibiotic prophylaxis for simple
AVF (e.g., creation of a native radiocephalic or native brachiocephalic
AVF) procedures.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

30. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

31. Creation of AVF
•Surgical technique (under regional block or local anaesthesia)
•Nowadays, endovascular techniques are available
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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There is inadequate evidence for the KDOQI Vascular Access Guideline (2019
Update) to make a recommendation on the preferred use of surgical or
endovascular techniques for postoperative maturation.

32. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

33. AVF post-operative instructions
•The arm should initially be kept elevated.
•Check the AVF daily for the presence of thrill and bruit.
•Avoid the following:
o Compression of the fistula during sleeping.
o Tight circumferential dressings.
o Venipuncture from the fistula.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

34. AVF post-operative instructions
KDOQI Vascular Access Guideline (2019 Update) statements for the AVF
post-operative period:
•Post-operative exercise:
o Inadequate evidence
o The whole arm
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

35. AVF post-operative instructions
KDOQI Vascular Access Guideline (2019 Update) statements for the AVF
post-operative period:
•Post-operative exercise:
o Inadequate evidence
o The whole arm
•The use of adjuvant far-infrared therapy to improve AVF primary
patency should be based on individual circumstances, feasibility, and
the clinician’s best judgment and expertise.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
https://firapy.com/2019/11/18/far-infrared-therapy-for-arteriovenous-fistulas/

36. AVF post-operative instructions
KDOQI Vascular Access Guideline (2019 Update) statements for the AVF
post-operative period:
•AVF should be evaluated by a surgeon/operator:
o Within 2 weeks of creation for early detection of any
postoperative complications
o Within 4–6 weeks of creation for signs of maturation.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

37. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

38. Post-operative mature AVF (rule of sixes)
•Maturation should typically occur 6 weeks following surgery.
•The venous segment should be less than 6 mm below the skin.
•The venous segment should be 6 mm in diameter.
•A straight venous segment with a minimum length of 6 cm is required for
cannulation.
•A minimum blood flow rate of 600 mL/min (500–800 mL/min through
forearm AVF).
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

39. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

40. AVF first use (cannulation)
•I. Day of the week
•II. Use “wet needle” technique
•III. Needle with a “backeye”
•IV. Needle size selection
•V. Use ultrasound
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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41. AVF first use (cannulation)
•I. Day of the week
•II. Use “wet needle” technique
•III. Needle with a “backeye”
•IV. Needle size selection
•V. Use ultrasound
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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•A day without dialysis
•Midweek treatment

42. AVF first use (cannulation)
•I. Day of the week
•II. Use “wet needle” technique
•III. Needle with a “backeye”
•IV. Needle size selection
•V. Use ultrasound
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Advantages of “wet needle” techniques:
•If saline infiltration occurs, the normal saline is less harmful to
the surrounding AVF tissue than if it was infiltrated by blood.
•It eliminates the potential for blood to leak or spill from the
needle when the caps are opened.

43. AVF first use (cannulation)
•I. Day of the week
•II. Use “wet needle” technique
•III. Needle with a “backeye”
•IV. Needle size selection
•V. Use ultrasound
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

44. AVF first use (cannulation)
•I. Day of the week
•II. Use “wet needle” technique
•III. Needle with a “backeye”
•IV. Needle size selection
•V. Use ultrasound
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

45. AVF first use (cannulation)
•I. Day of the week
•II. Use “wet needle” technique
•III. Needle with a “backeye”
•IV. Needle size selection
•V. Use ultrasound
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

46. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

47. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

48. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

49. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

50. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Arterial “inlet or
upstream” needle
pointing in a downstream
direction is popular but may
point upstream
Figure 9.3. Position characteristics of arterial and venous needle of arteriovenous access
https://evtoday.com/articles/2017-june-
supplement/dialysis-cannulation-direction-of-bevel-
and-blood-flow

51. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Arterial “inlet or
upstream” needle
pointing in a downstream
direction is popular but may
point upstream
Venous “outlet or
downstream” needle
inserted pointing
downstream (i.e., pointing
toward the heart)
3 cm away from
anastomotic site
Venous needle 5-6 cm
away from arterial needle
Figure 9.3. Position characteristics of arterial and venous needle of arteriovenous access

52. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

53. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
a. First technique: The “rope ladder” technique (rotational
cannulation approach)
b. Second Technique: Buttonhole cannulation technique

54. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
a. First technique: The “rope ladder” technique (rotational
cannulation approach)
b. Second Technique: Buttonhole cannulation technique

55. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Arterial cannulation
site rotation each
dialysis session
Venous cannulation
site rotation each
dialysis session
Figure 9.4. “Rope ladder” technique (rotational cannulation approach)

56. a. First technique: The “rope ladder” technique (rotational
cannulation approach)
b. Second Technique: Buttonhole cannulation technique
General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
a. First technique: The “rope ladder” technique (rotational
cannulation approach)
b. Second Technique: Buttonhole cannulation technique

57. Buttonhole cannulation technique
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
https://www.nxstage.com/hcp/products/buttonhole-av-fistula-needles-with-steripick/

58. Buttonhole cannulation technique
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
https://www.nxstage.com/hcp/products/buttonhole-av-fistula-needles-with-steripick/
Disadvantages of the buttonhole
technique:
•It increases the risk of infection.
•The degree of its success may be highly
technique-dependent.

59. Buttonhole cannulation technique
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
https://www.nxstage.com/hcp/products/buttonhole-av-fistula-needles-with-steripick/
KDOQI (2019 Update) limit AVF buttonhole
cannulation to:
•AVF has only a short or small segment
for cannulation.
•Enlarging or large aneurysm.
•Failure of rope-ladder cannulation for
cannulators (e.g., home hemodialysis).

60. https://forums.homedialysis.org/t/need-new-fistula/7184
Kidney News, 12(7), 14-15

61. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

62. Preventing of infiltration
•Lifting the needle up should be avoided after its insertion.
•Use of proper taping helps to prevent infiltration.
•Proper needle removal prevents post-dialysis infiltration.
•Monitor closely for any signs of infiltration.
•If infiltration happens, a prompt response is required.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

63. General instructions for regular cannulation of AVF
1.Educate the patient on washing the access arm
2.Skin preparation
3.Anesthesia with a topical cream
4.Use of tourniquets for AVF
5.Ultrasound use
6.Needle size
7.Arterial and venous needles positioning
8.Needle insertion angle
9.Needle axis rotation
10.Cannulation techniques
11.Preventing of infiltration
12.Hemostasis post-dialysis
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

64. Hemostasis post-dialysis
•Apply firm pressure using one or two fingertips. Ensure the pressure is not
too strong, which may obstruct the AV access flow.
•Pressure must be maintained for a minimum of 10 minutes before assessing
for bleeding at the puncture site.
•If prolonged bleeding >20 minutes, detect the cause.
•It is not advisable to apply any adhesive bandages until complete hemostasis
has been accomplished.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

65. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

66. Main indication and when should AVG be
created?
•AVG is indicated if an AVF cannot be created.
•AVG can be created when the patient is expected to start HD within 2-
4 weeks.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

67. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG
Generally, the preoperative evaluation for AVG is
similar to that of AVF.

68. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

69. AVG material
•Polytetrafluoroethylene (PTFE) grafts are the most commonly used.
•Biologic grafts (more likely to become aneurysmal than PTFE grafts).
•Other grafts (tapered, elastic , and heparin-bonded grafts) showed no
extra benefit over PTFE.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

70. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

71. AVG possible locations
•Looped forearm (brachial artery
to cephalic vein, or brachial
artery to the basilic vein).
•Straight forearm (radial artery
to cephalic vein).
•Looped upper arm (axillary
artery to axillary vein).
•Straight upper arm (brachial
artery to axillary vein).
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Semin Nephrol. 2002 May;22(3):183-94

72. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG
ERBP (2019): Perioperative prophylactic antibiotics for preventing
AVG infection
They recommend giving preoperative antibiotic prophylaxis for AVG
insertion.

73. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG
These are similar to that of AVF. There is no role
for arm exercises to help AVG maturation.

74. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

75. AVG first use (cannulation)
•After placement, a PTFE graft should not be cannulated before two
weeks. This duration is essential to ensure AVG maturation:
o Resolution of edema and erythema.
o Adhesion between the graft and the subcutaneous tunnel.
o Flow through a mature forearm AVG is about 1,000 mL/min.
•Premature AVG cannulation: infection and blood extravasation into
the tunnel
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

76. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

77. General instructions for regular cannulation of
AVG
•No need for the use of a tourniquet.
•Needle insertion angle: 45° angle with the bevel up.
•The buttonhole cannulation technique is not recommended in
synthetic PTFE graft cannulation because of the high risk of infection
of both the buttonhole and the AVG.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

78. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

79. Improving AVG patency: KDOQI Vascular
Access Guideline (2019 Update) suggestions
•Dipyridamole (200 mg) + aspirin (25 mg) twice daily to improve AVG
primary unassisted patency.
•Oral fish oil:
o Reduce patient morbidity.
o Inadequate evidence to prolong AVG cumulative patency.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

80. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

81. AVF versus AVG:
KDOQI Vascular Access Guideline (2019 Update) Considerations:
Change in concepts from “fistula first” to “patient first”
The main concept is changed by KDOQI (2019 Update) from “fistula
first” to “patient first” or, in other terms, “the right access, in the
right patient, at the right time,” as KDOQI considers it reasonable to
choose the site of the AV access after careful consideration of the
patient’s ESKD Life-Plan.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

82. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

83. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

84. AV access in the lower extremity has a high
complication rate and poor outcome.

85. Indication of “Lower extremity AVF or AVG” or
“HeRO Graft”
All arteriovenous access options in the upper extremity have been
exhausted.
+
The patient’s ESKD Life-Plan includes a long duration (e.g., >1 year) on
hemodialysis.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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AV access in the lower extremity has a high
complication rate and poor outcome.

86. Talk Outline: Chapter 9
Arteriovenous Fistula and Graft:
Basics, Creation, Use, and Examination
•Upper extremity arteriovenous fistula (AVF)
oMain idea
oVessel preservation
oWhen should AVF be created?
oAVF preoperative evaluation:
✓Patient history
✓Preoperative physical examination
✓Preoperative imaging
oAVF types and possible locations
oTechniques of anastomosis
oPerioperative prophylactic antibiotics
oCreation of AVF
oAVF post-operative instructions
oPost-operative mature AVF (rule of sixes)
oAVF first use (cannulation)
oGeneral instructions for regular cannulation of AVF
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•Upper extremity arteriovenous graft (AVG)
oMain indication and when should AVG be created?
oAVG preoperative evaluation
oAVG material
oAVG possible locations
oPerioperative prophylactic antibiotics
oAVG post-operative instructions
oAVG first use (cannulation)
oGeneral instructions for regular cannulation of AVG
oImproving AVG patency
•AVF versus AVG
•“Lower extremity AVF or AVG” or “HeRO Graft”
•Clinical monitoring (physical examination) of AVF and AVG

87. Clinical monitoring (physical examination) of
AVF and AVG
•Noninvasive and cost-effective for evaluating AV access.
•Can detect and localize stenotic lesions in most patients with AV
access.
•Before every cannulation.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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88. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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89. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

90. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

91. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Wrist radiocephalic
AVF scar
Brachiocephalic
AVF scar
Transposed brachiobasilic
AVF scar
Figure 9.5. Arteriovenous fistulas scar site

92. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

96. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

98. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

99. Signs of hand ischemia
(steal syndrome)

100. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

101. Stable Aneurysm
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▪Overlying skin is intact without any change
in pigmentation.
▪The fistula has no evidence of outflow
obstruction on physical examination by arm
elevation test.
▪Stationary aneurysm size.

102. Unstable Aneurysm “impending rupture”
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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▪Thin and shiny overlying skin.
▪Depigmentation of overlying skin.
▪Ulceration of overlying skin.
▪Rapid enlargement in size.
▪Prolonged leaking after needle removal.

103. Unstable Aneurysm “impending rupture”
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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▪Thin and shiny overlying skin.
▪Depigmentation of overlying skin.
▪Ulceration of overlying skin.
▪Rapid enlargement in size.
▪Prolonged leaking after needle removal.

104. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

108. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
1.Vascular access scar site
2.Signs of infection/inflammation
3.Infiltration and/or hematoma
4.Signs of hand ischemia (steal syndrome)
5.Aneurysm/Pseudoaneurysm
6.Signs of central vein stenosis
7.Notice any scars

109. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Palpate AV access pulse and thrill characters
2.Access versus non-access extremity

110. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
1.Palpate AV access pulse and thrill characters
2.Access versus non-access extremity

111. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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112. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Palpate AV access pulse and thrill characters
2.Access versus non-access extremity

113. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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114. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.AV access auscultation
2.Heart auscultation

115. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.AV access auscultation
2.Heart auscultation

116. AV access auscultation
oNormally: Continues bruit (systolic and
diastolic).
oOutflow (downstream) stenosis: High
pitched loud, discontinuous bruit
immediately downstream (i.e.,
proximal near to heart) from stenosis.
oInflow (upstream) stenosis: Low-
pitched quiet bruit.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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117. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.AV access auscultation
2.Heart auscultation
For early detection of newly formed murmurs
(?? infective endocarditis)

118. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Arm elevation test
2.Augmentation test
3.Sequential occlusion test

119. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Arm elevation test
2.Augmentation test
3.Sequential occlusion test

120. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Outflow
Stenosis
Normally:
Collapse
A B
Figure 9.6. Arm elevation test

121. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Arm elevation test
2.Augmentation test
3.Sequential occlusion test

122. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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After occlusion: normally: Pulse
augmentation, Absence of Thrill
No Pulse augmentation,
No thrill
= Inflow stenosis
No Pulse augmentation,
Normal thrill
= Accessory Vein(s)
B
C D
Before occlusion
A
Figure 9.7. Augmentation test

123. Clinical monitoring (physical examination) of
AVF and AVG
•I. Inspection (Look)
•II. Palpation (Feel)
•III. Auscultation (Listen)
•IV. AV access specific tests
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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1.Arm elevation test
2.Augmentation test
3.Sequential occlusion test

124. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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To detect the level of
accessory veins
Still No Pulse augmentation,
Normal thrill
Augmentation, No thrill = Level of
accessory vein detected
Figure 9.8. Sequential occlusion test

125. Thank You