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Published online before print December 5, 2001, 10.1148/radiol.2221991095
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(Radiology 2002;222:103-107.)
© RSNA, 2001

Ultrasonography

Management of Suspected Hemodialysis Graft Dysfunction: Usefulness of Diagnostic US1

Michael C. Dumars, MD, William E. Thompson, MD, Edward I. Bluth, MD, Jill S. Lindberg, MD, Moises Yoselevitz, MD and Christopher R. B. Merritt, MD

1 From the Department of Radiology, University of California Davis (M.C.D.); the Department of Radiology, Ochsner Clinic Foundation, 1516 Jefferson Hwy, New Orleans, LA 70121 (W.E.T., E.I.B., M.Y.); the Department of Nephrology, Ochsner Clinic Foundation, New Orleans, La (J.S.L.); and the Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (C.R.B.M.). From the 1998 RSNA scientific assembly. Received June 7, 1999; revision requested August 3; final revision received August 13, 2001; accepted August 15.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To evaluate the role and usefulness of diagnostic ultrasonography (US) in the assessment of hemodialysis access grafts with an intermediate probability of graft malfunction.

MATERIALS AND METHODS: One hundred forty-seven complete US examinations were performed in 91 patients. Average volume of flow, peak systolic velocity, and diameter of residual lumen were recorded. Patients were referred by the nephrology department when clinical findings were suggestive, but not obviously, of graft malfunction. Study results were deemed normal if flow volume exceeded 1,300 mL/min without significant visualized stenosis of 50% of the diameter or greater or if flow approached 1,300 mL/min without peak systolic velocity greater than 400 cm/sec.

RESULTS: Of the 147 examinations, 49 (33%) had normal results, seven (5%) showed thrombosis at examination, and 91 (62%) had evidence of at least one significant visualized stenosis or diffuse notable degree of thrombus. Three patients with normal results required fistulography within 90 days, one for thrombosis. In the 91 studies with abnormal results, 69 patients underwent fistulography; results in 63 showed agreement, and three showed false-positive results. More central venous stenoses were found at fistulography than at US.

CONCLUSION: US is a useful and reliable first step in managing clinically suspected hemodialysis graft stenosis. One-third of the studies showed no significant stenosis and did not require angiographic evaluation. US should be the initial study in patients suspected of having hemodialysis access dysfunction without exceptional evidence of stenosis.

Index terms: Dialysis, shunts, 91.442, 91.457, 91.4522 • Ultrasound (US), Doppler studies, 91.12983


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Color Doppler ultrasonography (US) is a well-established method for the detection of vascular stenosis in numerous parts of the body, including the extracranial carotid arteries, renal arteries, and arteries of the lower extremities (1–5). Many criteria may be used to help detect stenoses, including elevated peak systolic velocity, elevated diastolic velocity, and altered velocity ratios. Authors of previous studies (6–11) have evaluated the accuracy of duplex US in detection of significant stenosis (ie, 50% or greater) of hemodialysis access grafts, and found that (a) color Doppler US is more sensitive than clinical or laboratory methods for detection of hemodialysis access stenosis and (b) Doppler US is an accurate means for detection of hemodialysis access stenosis. Results of studies (9,10,12,13) have shown that a decreased volume of flow through the graft is associated with an increased risk of thrombosis. Sands et al (9) demonstrated that elective revision substantially decreased the incidence of clotting in hemodialysis access graft with flow of 1,300 mL/min or less.

Authors of previous studies have also used US in a screening program at regular intervals, in a population with clinical or laboratory findings suggestive of stenosis, or in an asymptomatic population as a means of detecting stenoses (14). While there is evidence that institution of a screening program at regular intervals may be the optimal means of managing hemodialysis access graft, this may not be feasible for some practices. Although studies performed with patients with clinical or laboratory signs of hemodialysis access graft dysfunction have shown that US is an accurate and sensitive means of detecting hemodialysis access graft stenoses, the value of examining a population with a high incidence of stenosis with US before referral for fistulography is questionable. The purpose of this study was to (a) examine the effectiveness of color Doppler flow imaging by using gray scale, peak systolic velocity, and flow rate in the detection of significant stenosis (ie, greater than 50%) in patients with an intermediate probability of graft dysfunction on the basis of clinical findings or symptoms suggestive of hemodialysis access graft stenosis and (b) determine the actual incidence of stenosis in this population and whether color Doppler flow imaging would be of any value in screening a population of patients who subsequently would undergo an expensive invasive procedure.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Between July 1, 1996, and December 31, 1997, 91 patients underwent a complete color Doppler flow imaging evaluation of their hemodialysis polytetrafluoroethylene grafts for a total of 147 examinations. Patients were referred by the nephrologist (J.S.L.) in charge of hemodialysis access graft management. Patients were excluded from the study if they were referred for examination of arteriovenous fistula and were undergoing renal transplantation, died, or discontinued dialysis before fistulographic findings could be used to confirm color Doppler flow imaging findings.

Referral criteria included decreased kinetics values—poor blood flow at dialysis, abnormal volume of distribution of urea, or decreased flow rates; inability to properly cannulate the hemodialysis access graft; frequent prolonged bleeding after cannulation; pain; or elevated venous pressures. These criteria were used with the knowledge of Dialysis Outcomes Quality Initiative, or DOQI, guidelines (15). Patients with a high clinical suspicion of having stenosis, such as those with grafts with a history of stenosis, those with symptoms that indicated stenosis in the past, or those with trends in kinetics or clinical findings strongly suggestive of stenosis, were sent directly for fistulography at the discretion of the referring nephrologist. Consultation with our institutional review board indicated that its approval was not required for this study, nor was patient informed consent required.

All US studies were performed in the US department (HDI 3000 ATL or Ultramark 9; Advanced Technology Laboratories, Bothell, Wash). All studies were performed by certified vascular technologists experienced in the procedure. The studies and calculations were interpreted by any of five radiologists (E.I.B. and others), none of whom performed subsequent fistulography. The laboratory is certified by the Intersociety Commission on Accreditation of Vascular Laboratories, or ICAVAL.

The entire hemodialysis access graft was evaluated, including the feeding artery and draining vein to the level of the subclavian vein. The graft was subdivided into the proximal graft including the arterial anastomosis, the middle of the graft, and the distal graft including the venous anastomosis. Average volume of flow, peak systolic velocity, and the location and diameter of any narrowed areas were calculated or recorded. Any narrowed areas were measured in transverse diameter. All measurements were obtained from waveforms with an insonating angle of less than 60° when possible.

Flow volume was calculated from the sagittal measurement and mean velocity measurements at the area of narrowing. Stenosis was considered significant if either the peak systolic velocity was greater than 400 cm/sec with volume of flow less than 1,300 mL/min or narrowing of 50% or more at gray-scale imaging, or if the volume of flow was less than 1,300 mL/min at any point of narrowing in the graft. Stenosis was confirmed and estimated by means of gray-scale imaging. After the examination, referral for fistulography or surgery was determined by the referring nephrologist on the basis of clinical parameters including age, previous graft problems, and likelihood of success with percutaneous transluminal angioplasty. For all patients with normal or nearly normal examination results, records were reviewed to assess the continued patency and working order of the graft within 90 days after US.

Fistulography was performed and the images interpreted by any of four dedicated interventional radiologists (M.Y. and others) in the angiography division of the diagnostic radiology department. The location and diameter of the residual lumen were recorded. Patients with significant stenoses at fistulography underwent percutaneous transluminal angioplasty if considered suitable candidates for such a procedure. Thrombolysis was also performed if necessary.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 147 examinations, 49 (33%) showed normal results (Fig 1), seven (5%) showed thrombosis at the time of the examination, and 91 (62%) had evidence of at least one significant stenosis or diffuse notable degree of thrombus. Sixteen stenoses occurred in the proximal graft including the arterial anastomosis, two in the middle of the graft, and 60 in the distal graft including the venous anastomosis (Fig 2). In seven, significant stenosis was detected on the basis of the flow volume less than 1,300 mL/min in the absence of peak systolic velocity of greater than 400 cm/sec or more. In addition, color Doppler flow imaging results were suggestive of 14 stenoses in the draining veins or central vasculature.



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  		Figure 1a. (a) Power Doppler image of the distal venous limb of the hemodialysis access graft at the anastomosis with the basilic vein with a normal (4-mm) transverse diameter (crosshairs). This was the narrowest area of the graft. (b) Power Doppler image at the same level as a demonstrates normal flow characteristics at spectral analysis, peak systolic velocity of 268 cm/sec, and an average flow greater than 1,300 mL/min.

 


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  		Figure 1b. (a) Power Doppler image of the distal venous limb of the hemodialysis access graft at the anastomosis with the basilic vein with a normal (4-mm) transverse diameter (crosshairs). This was the narrowest area of the graft. (b) Power Doppler image at the same level as a demonstrates normal flow characteristics at spectral analysis, peak systolic velocity of 268 cm/sec, and an average flow greater than 1,300 mL/min.

 


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  		Figure 2a. (a) Power Doppler image of the distal venous limb of the hemodialysis graft proximal to the basilic venous anastomosis. The transverse diameter of the focal stenosis was 0.29 cm. (b) Color Doppler flow image at the area of narrowing of the dialysis graft demonstrates spectral broadening due to turbulent flow and a peak systolic velocity of 635 cm/sec. This corresponds to an average flow of 429 mL/min.

 


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  		Figure 2b. (a) Power Doppler image of the distal venous limb of the hemodialysis graft proximal to the basilic venous anastomosis. The transverse diameter of the focal stenosis was 0.29 cm. (b) Color Doppler flow image at the area of narrowing of the dialysis graft demonstrates spectral broadening due to turbulent flow and a peak systolic velocity of 635 cm/sec. This corresponds to an average flow of 429 mL/min.

 
Of the 91 patients with abnormal nonthrombosed examination results, 69 underwent fistulography within 30 days after color Doppler flow imaging. An additional five patients underwent a surgical procedure for lesions not considered amenable to percutaneous repair techniques. The nephrologist did not follow up eight patients because of nearly normal color Doppler flow imaging results, and nine refused fistulography or were lost to follow-up. Of the 69 undergoing fistulography, 63 (91%) had results that agreed when correlated with the color Doppler flow imaging findings. Of the six patients with disagreeing results, three showed normal or nearly normal findings at fistulography. One had a significant stenosis elsewhere in the graft; at US it appeared to be a central venous stenosis, and at fistulography it appeared to be venous anastomoses. Two had overestimated stenoses at the arterial anastomoses, with stenoses of the draining veins identified at fistulography. An additional three patients had stenoses of the draining or central veins in addition to the critical lesion seen on color Doppler flow images.

Two patients with abnormal examination results presented with thrombosis at the time of scheduled fistulography. No patients with normal examination results subsequently developed thrombosis of the graft within 30 days after color Doppler flow imaging. One developed thrombosis 7 weeks after the study. Three patients with normal examination results subsequently had central venous stenosis and required fistulography within 90 days, one for thrombosis. In patients with a volume of flow approaching but less than 1,300 mL/min, correlation with the gray-scale findings and flow within the feeding artery were used to judge if a critical stenosis existed.

On the basis of angiographic or surgical correlation, and given that the normal and nearly normal study results that did not subsequently need evaluation within 30 days were at least clinically accurate, 68 of 74 clinically important lesions were detected for a sensitivity of 92%. Sixty-three of 69 correlated with color Doppler flow imaging findings for a positive predictive value of 91%. Only three of 49 normal examination results had a significant stenosis (central venous) for a specificity of 94%.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Early detection and treatment of stenoses by means of percutaneous transluminal angioplasty has been shown in the literature to be highly successful in prevention of hemodialysis access graft thrombosis and may prolong the life of the hemodialysis access graft (14,16–18). Strauch et al (19) found that 57% (eight of 14) of the grafts with stenosis greater than 50% at the venous anastomosis underwent thrombosis within 6 months after diagnostic US. Sands et al (9) found a 92.8% thrombosis rate within 6 months after US in patients with synthetic grafts and flow of 801 mL/min or less. Results of multiple other studies have been used to confirm the diagnostic accuracy of US as a means of detecting critical stenoses. Middleton et al (20) demonstrated a high degree of accuracy by using visual assessment of the color Doppler image as a means of detecting stenosis. Tordoir et al (21) showed the maximum systolic frequency to be a sensitive index.

Our criteria for stenosis were based on data from the radiology literature (22) and a normal volume of flow value less than 1,300 mL/min (9). We believe that volume of flow can be used as a predictor of stenosis severity. Our results can be used to confirm the high accuracy of color Doppler flow imaging and show that in a clinically preselected population, color Doppler flow imaging can substantially reduce the number of subsequent fistulographic examinations. It should also be noted that by using the criteria of peak systolic velocity greater than 400 cm/sec without correlation to gray-scale or color Doppler flow findings, 26 of 49 examinations with a high volume of flow through the graft but no significant stenosis would have been identified as suggestive of graft dysfunction. It seems that both the color Doppler and gray-scale findings, as well as the volume of flow, should be correlated with peak systolic velocity before the diagnosis of a significant stenosis is suggested.

Alternately, Robbin et al (8) showed that an elevated peak systolic velocity ratio, along with other criteria, is a sensitive index of stenosis. Use of the peak systolic velocity ratio may increase the specificity of evaluating grafts with an increased peak systolic velocity greater than 400 cm/sec. Unfortunately, we could not retrospectively evaluate this possibility.

Although a high degree of accuracy was present when evaluating the graft, overestimation of stenoses at the arterial anastomoses was noted in multiple studies. This is a potential pitfall because this area may taper normally for creation of the anastomosis (8). Careful evaluation of the Doppler shift, possibly by using velocity ratios, may have prevented these errors. Three patients in these studies subsequently had draining or central venous stenoses. In addition, three patients with normal examination results subsequently had central venous stenoses. Although we found a number of stenoses in the draining vasculature, this area can be difficult to evaluate accurately for focal stenosis in the absence of thrombosis or other obvious signs of obstruction. We know of no reference specifically addressing the sensitivity of US in the evaluation of nonthrombosed obstruction of the upper extremity venous outflow.

Although early detection may decrease the incidence of thrombosis and graft failure, screening fistulography or US may not be feasible in many centers. Noninvasive means of detection, such as clinical criteria and US, have been examined (23). Multiple clinical criteria have been used to screen patients for referral for fistulography. Schwab et al (24) found hemodynamically significant stenoses in 86% (50 of 58) of patients with elevated venous dialysis pressures. Safa et al (25) used multiple clinical parameters in a surveillance program as indicators for performing fistulography.

US has been shown to be more reliable than clinical criteria in the detection of hemodialysis access graft stenosis. Dousset et al (6) and Older et al (7) found screening US accurate in identifying significant stenosis greater than 50%, with a high prevalence (80% [32 of 40]) of stenoses in an asymptomatic population. Authors of other studies (6,8) have documented a correlation greater than 90% between fistulography and US. Neyra et al (26) showed that a decrement in blood flow is associated with an increased risk of hemodialysis access graft thrombosis.

Although early detection has been shown to be an important factor in reducing the episodes of thrombosis, screening US in an asymptomatic population is not routinely available. It would seem reasonable in these instances to define a screening program that would identify patients at greatest risk and refer them directly for fistulography, with screening for the remainder of those at moderate risk. This would limit the population undergoing unnecessary interventional procedures and prevent needless redundancy in the use of both US and fistulography. This study combines a clinical screening method with color Doppler flow imaging as a means of detecting graft stenosis. Patients with such a high probability of stenosis that US would be an unnecessary test were referred directly for fistulography.

Our results show that in a population with a moderate risk of thrombosis, almost one-third of the examinations will have normal color Doppler flow imaging results, and these patients may be excluded from further imaging. None of these patients presented with thrombosis within 30 days after the examination, which confirms the accuracy and reliability of normal color Doppler flow imaging results. Color Doppler flow imaging is also accurate in the evaluation of these grafts, with 68 of 74 lesions showing substantial agreement when followed with fistulography. Although multiple US parameters have been used for detection of hemodialysis access graft stenosis (6,8,21,27), we found the addition of the flow volume measurement to be most helpful in excluding those patients with elevated peak systolic velocity and no or minor evidence of narrowing at gray-scale examination. Our results can also be used to confirm the prevalence of stenosis at or near the venous anastomosis (28).

In summary, we conclude color Doppler flow imaging is a valuable and accurate screening tool for hemodialysis polytetrafluoroethylene grafts in a population suspected of having graft malfunction. Screening this population with color Doppler flow imaging reliably identifies patients who need further evaluation and possible intervention. Since nearly one-third of patients had clinical findings suggestive of graft dysfunction but had normal color Doppler flow imaging results, it would seem logical to screen this population before referral for fistulography.


   FOOTNOTES
 
Author contributions: Guarantors of integrity of entire study, M.C.D., W.E.T., E.I.B.; study concepts, M.C.D., E.I.B., J.S.L., C.R.B.M.; study design, M.C.D., E.I.B., C.R.B.M., J.S.L., M.Y.; literature research, M.C.D., E.I.B., J.S.L.; clinical studies, E.I.B., C.R.B.M., J.S.L., M.Y.; data acquisition, M.C.D., W.E.T., C.R.B.M.; data analysis, all authors; manuscript preparation, M.C.D., E.I.B., J.S.L.; manuscript definition of intellectual content, M.C.D., E.I.B.; manuscript editing and review, M.C.D., E.I.B., J.S.L.; manuscript final version approval, all authors.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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