The AIUM Practice Parameter for the Performance of Ultrasound Vessel Mapping Prior to Dialysis Access Creation
2021; Wiley; Volume: 41; Issue: 4 Linguagem: Inglês
10.1002/jum.15876
ISSN1550-9613
Tópico(s)Vascular Procedures and Complications
ResumoJournal of Ultrasound in MedicineVolume 41, Issue 4 p. E16-E20 Practice ParameterFree Access The AIUM Practice Parameter for the Performance of Ultrasound Vessel Mapping Prior to Dialysis Access Creation First published: 18 November 2021 https://doi.org/10.1002/jum.15876AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM Practice Parameter for the Performance of Ultrasound Vessel Mapping Prior to Dialysis Access Creation was revised by the AIUM in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This practice parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but is not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the parameter with the recognition that deviations may occur depending on the clinical situation. Indications Indications for preprocedural vessel mapping include assessment of arterial and venous systems prior to procedural planning of hemodialysis access creation. There are no absolute contraindications for this examination. Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines in accordance with AIUM accreditation policies. Sonographers performing the ultrasound examination should be appropriately credentialed in the specialty area in accordance with AIUM accreditation policies. Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32. Request for the Examination The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed healthcare provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local healthcare facility requirements. Specifications of the Examination The ultrasound examination for vessel mapping is designed to gather anatomic and hemodynamic information about both the arterial and venous systems. It is important to understand the procedure and procedural options available to the access surgeon(s) to obtain the required information. Both arms can be mapped in their entirety, or a more focused preprocedural mapping can be performed that concludes when vessels adequate for arteriovenous fistula (AVF) formation are found, based on local preference. Of note, all artery and vein inner lumen measurements are performed in the anteroposterior dimension in the transverse plane, taking care to not compress the vessel from its normal round shape by transducer pressure. Arterial Examination The arm examination can be bilateral or unilateral, depending on laboratory and surgeon preference. If a unilateral examination is performed, the nondominant arm is examined first unless there is a contraindication to the use of that arm. The artery used must be of sufficient size to construct the fistula and to provide enough flow for maturation and adequate hemodialysis treatment. This size may vary according to procedural preference. Generally, accepted minimum vessel size criteria are the inner diameter of ≥0.20 cm, but this may vary with a trend toward increasing unassisted AVF maturation with increasing artery size.1-8 The artery is evaluated with grayscale and spectral Doppler imaging. Grayscale ultrasound is useful for the evaluation of calcifications and plaque formation. Color and spectral Doppler waveform analysis can aid in the detection of inflow and outflow disease. The internal luminal diameter of the artery is measured at the level of expected fistula creation with the measurements obtained in the short axis of a vessel in transverse and anterior–posterior dimensions. The presence of calcification at this site is also recorded and reported because procedural anastomosis can be difficult if significant concentric calcification is present. For a forearm AVF, diameter, the presence of calcification, and peak systolic/end-diastolic velocities of the radial artery are assessed at the wrist. Ulnar arteries may be similarly assessed. For either AVF or arteriovenous graft surgery, the brachial artery is assessed at the antecubital fossa for diameter, the presence of calcification, and peak systolic/end-diastolic velocities. An artery in the antecubital fossa that is smaller than expected or the presence of 2 arteries at this site is a clue that there is a high brachial artery bifurcation, a normal anatomic variant that occurs in approximately 10% of patients.9 This anatomic variant should be confirmed by imaging the radial and ulnar arteries to determine at what level they arise from the brachial artery. If noted, it should be reported, as some physicians will place an AVF, but not a graft, distal to a high brachial artery bifurcation. A modified duplex Allen test may be performed to evaluate flow to the hand (patency of the deep palmar arch). This is done by identifying the radial artery at the wrist and/or at the dorsum of the hand (posteriorly between the bases of the first and second metacarpals). The radial artery is compressed proximal to this site to occlude flow during insonation with spectral and color Doppler. Reversal of blood flow distal to the proximal occlusion confirms patency of the palmar arch.10 Venous Examination The nondominant arm is examined first unless there is a known contraindication to the use of that arm. The vein that is planned to receive the arterial anastomosis should be measured after it is dilated. Measurement of the vein after application of a tourniquet will more closely approximate the size of the arterialized vein following fistula formation. The vein is generally dilated by use of sequential tourniquet placement or an inflated blood pressure cuff on the arm.11, 12 Percussion in the region of the wrist after tourniquet placement for 2 to 3 minutes can increase the size of the veins, similar to starting an intravenous (IV) line. Other suitable dorsal or volar caudal forearm veins may be identified with this technique. If no suitable vein is found, veins suitable for graft creation are sought. The forearm vein most commonly used for AVF creation is the cephalic vein. The anastomosis is usually created at the wrist or in the lower one-third of the forearm. The cephalic vein is assessed throughout its course from the level of the wrist (a site of potential anastomosis) to the level of the confluence with either the subclavian or axillary vein for patency, compressibility, the presence of thrombus, depth from the skin, and size. Size measurements are obtained for all veins. Generally, a minimum diameter of 0.25 cm is acceptable, although there may be variations based on clinical factors or procedural preference.1-7 Vein diameter is measured at the proximal, mid, and distal forearm; at the antecubital fossa; and at the proximal, mid, and distal upper arm, as applicable. If venous stenosis is detected, the location, diameter, and length of the stenotic segment are reported. Veins that are borderline in size (within 0.05 cm of the desired size) are remeasured after dilatation in response to manually focused percussion or after temporary application of a warm compress. If a sclerotic or thick-walled vein is seen, its inner luminal diameter is measured and documented. Focal narrowing of the vein at any level may preclude the maturation of an AVF. Note that in case of more central cephalic vein thrombosis or hypoplasia, the forearm portion of the cephalic vein may drain preferentially via a large antecubital vein into the basilic or brachial veins. The creation of a forearm fistula is still possible as long as diameter thresholds are maintained. Successful AVF maturation is best achieved with a vein diameter of 0.25 cm or greater, although there may be variations based on clinical factors or procedural preference.1-7 Veins must be relatively superficial to be easily accessed after the creation of a fistula. The distance from the skin surface to the cephalic vein may be measured to assess the need for a subsequent superficialization procedure.12, 13 If the cephalic vein in the forearm is found to be inadequate for fistula creation, other veins in the forearm may be examined in a similar fashion to determine whether they are adequate. Transposition to a more superficial location may be required to improve the accessibility of the vein during dialysis. If no suitable vein is found in the forearm, the veins in the upper arm are evaluated. If the cephalic vein is too small, thick-walled, or contains a thrombus, the basilic vein is evaluated. The basilic vein needs to be of adequate diameter and at least 4 cm in length caudal to the antecubital fossa in the proximal forearm or there must be an adequate median cubital vein draining into the basilic vein so there is enough vein length to create a basilic vein transposition AVF in the upper arm. If no suitable upper arm vein for AVF creation is found, the largest brachial vein and the axillary vein should be measured for potential graft placement as previously described. A vein with a diameter of at least 0.4 cm has been suggested for grafts.1, 14 Similar assessment techniques should be applied for all veins evaluated (i.e., vein inner lumen measurement after dilatation, demonstration of patency, compressibility, and determination of adequate venous drainage). A comment should be made about the presence of large associated vein accessory branches as they may result in fistula nonmaturation.15, 16 The sites and sizes of accessory vein branches within the first 10 to 15 cm of the expected AVF draining vein may be documented. The internal jugular and subclavian veins should be examined bilaterally to document symmetric respiratory phasicity and transmitted cardiac pulsatility, as well as to exclude outflow stenosis. These veins should be evaluated with compression if possible, with grayscale, spectral, and color Doppler. Unilateral or bilateral monophasic waveforms or low-velocity venous waveforms are abnormal.17, 18 Abnormal waveforms in the jugular or subclavian veins should prompt further evaluation of the brachiocephalic veins and/or superior vena cava (SVC) by magnetic resonance imaging, computed tomography, or conventional venography if hemodialysis access creation on that side is desired.19 Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination. The initials of the operator should be accessible on the images or electronically on PACS. Equipment Specification Equipment performance monitoring should be in accordance with the AIUM Routine Quality Assurance of Clinical Ultrasound Equipment, Version 2.0.20 Real-time imaging should be conducted at the highest clinically appropriate frequency, realizing that there is a tradeoff between resolution and beam penetration. This should usually be at a frequency of 12–18 MHz, with the occasional need for a lower-frequency transducer. A linear transducer should be used. Flow analyses are performed with duplex sonography using pulsed Doppler. Evaluation of the flow signals originating from within the lumen of the vessels should be conducted with a carrier frequency of 2.5 MHz or above. A lower-frequency sector transducer placed in the sternal notch may be useful to look for venous stenosis in the brachiocephalic veins or SVC if central stenosis is suspected from abnormal subclavian and internal jugular vein waveforms. Images of the relevant grayscale, color, and spectral Doppler waveforms should be recorded and archived. Color Doppler should be used for relevant portions of the procedure. Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. ALARA (as Low as Reasonably Achievable) Principle The potential benefits and risks of each examination should be considered. The ALARA principle should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety. Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel. Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice. Acknowledgments This parameter was developed by the AIUM in collaboration with the American College of Radiology (ACR) and the Society of Radiologists in Ultrasound (SRU). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees AIUM George Berdejo, BA, RVT, FSVU Margarita V. Revzin, MD, MS, FSRU, FAIUM ACR Michelle L. Robbin, MD, MS, FACR, FAIUM, FSRU, Chair Christopher Fung, MD Sheila Sheth, MD, FACR SRU Wui Kheong Chong, MD Comment Reconciliation Committee Elizabeth Ann Ignacio, MD, chair Eve Clark, MD, co-chair Susan J. Back, MD Richard A. Barth, MD, FACR George Berdejo, BA, RVT, FSVU Wui Kheong Chong, MD Richard Duszak Jr., MD, FACR Christopher Fung, MD Lauren P. Golding, MD Amy Kotsenas, MD, FACR David B. Larson, MD, MBA Paul A. Larson, MD, FACR Terry L. Levin, MD, FACR Mary S. Newell, MD, FACR Margarita V. Revzin, MD, MS, FSRU, FAIUM Michelle L. Robbin, MD, MS, FACR, FAIUM, FSRU Sheila Sheth, MD, FACR AIUM Clinical Standards Committee James M. 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