Change Concept 3

Early referral to surgeon for “AVF only” evaluation and timely placement

  • Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery referral.
  • Nephrologist refers for vessel mapping where feasible, prior to surgery referral.
  • Nephrologist refers patients to surgeons for “AVF only” evaluation, no later than Stage 4 CKD (GFR<30). Surgery scheduled with sufficient lead-time for AVF maturation.
  • Nephrologist defines AVF expectations to surgeon, including vessel mapping (if not already performed).
  • If timely placement of AVF does not occur, nephrologist ensures that patient receives AVF evaluation and placement at the time of initial hospitalization for temporary access (e.g. catheter).

When possible, coordinate chronic kidney disease patient care so that patients will be referred early to surgeons specifically for AV fistula evaluation, including vein mapping where indicated, allowing sufficient lead-time for AV fistula maturation.  Studies show that mapping vessels can significantly increase the incidence of successful AV fistulae.  Establish the understanding with your surgeons that they will contact you before placing anything other than an AV fistula.  Where timing is such that a temporary access must be placed (e.g., catheter), arrange for evaluation (and placement, if feasible) of an AV fistula during the initial hospitalization.

Changes for Improvement:

Refer Patients for Vessel Mapping

Nephrologists should refer patients for vessel mapping (identification of vessel anatomy) where feasible, ideally prior to surgery referral.  Doppler ultrasound or alternate technique should be used to search for suitable vessels that may be too deep to be identified on physical exam.  Numerous studies have shown that vessel mapping identifies vessels suitable for an AV fistula in the majority of patients where physical exam alone classified the patient as not being a candidate for an AV fistula.

Schedule Surgery with Sufficient Lead-Time for AVF Maturation

In order to schedule surgery with sufficient lead-time for AV fistula maturation, nephrologists should refer patients to surgeons for “AVF only” evaluation no later than Stage 4 CKD (GFR<30).

Communicate AVF Expectations (including Vessel Mapping) to Surgeons

Nephrologists should establish an understanding with surgeons that all patients should be fully evaluated for the possibility of an AV fistula, including vessel mapping where necessary.

Related Tools

FFBI Redefines Its Message

Special communication reinforcing FFBI’s goal for the reduction in morbidity and mortality associated with nonautogenous methods of hemodialysis access (catheters and arteriovenous grafts) and the achievement of an autogenous access rate of 66% in prevalent hemodialysis patients.

Sample Letter to Vascular Access Surgeon

Patient referral letter template from nephrologist to vascular surgeon requesting evaluation vessel mapping and permanent hemodialysis vascular access creation, with preference for a native AV fistula.

Referral Form for New Hemodialysis Access

A form designed for use by nephrologists for patient referral to a vascular surgeon for a new hemodialysis access including nephrologist site preference and protocol for instances when the preferred access will not be placed.

Consensus Document on Pre-Op Hemodialysis Access Mapping Protocol

A form with procedures for vessel mapping.

Duplex of Upper Extremity Vessels Prior to AV Fistula Surgery Protocol

Vessel mapping protocol to assess the patency and suitability of the arteries and veins for use as a dialysis arteriovenous fistula (AVF). Revised 01/10

Vessel Templates and Sample Reports

Sample vessel templates (venous & arterial) with sample reports (venous and arterial maps) developed by Larry Spergel, MD. Provided: 03/10