Change Concept 5

Full range of appropriate surgical approaches to AVF evaluation and placement

  • Surgeons utilize current techniques for AVF placement including vein transposition.
  • Surgeons ensure mapping is performed for any patient not clearly suitable for AVF based only on physical exam.
  • Surgeons work with nephrologists to plan for and place secondary AVFs in suitable AV graft patients.

Surgeons who are skilled in vein transposition techniques are able to create successful AV fistulae in a substantially greater number of patients.  These options require vein mapping and a surgeon’s willingness to put in the additional time and effort.  Make sure surgeons understand the logistics of cannulation so that they position the veins suitably and safely for cannulation.

Changes for Improvement:

Utilize Current Techniques for AVF Placement, including Vein Transpositions

Surgeons should utilize current techniques for AV fistula placement including vein transpositions.

Perform Mapping When Suitable Vessels Are Not Found on Physical Exam

Surgeons should ensure mapping is performed for any patient who is not deemed suitable for AV fistulae based solely on physical exam.

Related Tools

Consensus Document on Pre-Op Hemodialysis Access Mapping Protocol

This form from the Society for Vascular Ultrasound provides the proceure for vessel mapping.  Also see Change Concept #3

Duplex of Upper Extremity Vessels Prior to AV Fistula Surgery Protocol

Use this vessel mapping protocol to assess the patency and suitability of the arteries and veins for use as a dialysis arteriovenous fistula (AVF). The cephalic and basilic veins are preferred AVF conduits for hemodialysis. The patient is usually first referred from the nephrologist to the surgeon for AVF evaluation. After examining the patient, the surgeon selects the preferred extremity for the preoperative mapping study. If suitable vessels are identified, the necessity of performing a bilateral study can be avoided; if suitable vessels are not identified in the preferred extremity, then the contralateral extremity will need to be studied as well.

How to Make Fistulas That  Work

Creating AV Fistulae in all Eligible Hemodialysis Patients

The following is a training video program designed for surgeons and interventionalists. These videos were developed by William Jennings, MD and Lawrence Spergel, MD.