Increasing use of autogenous fistulas: Selection of dialysis access sites by duplex scanning and transposition of forearm veins

Although the autogenous radiocephalic fistula is considered to be the ideal access for hemodialysis, significant changes in the demographics of patients undergoing angioaccess have occurred since its initial description in the 1960s. Patients presenting for initial access evaluation in contemporary practice are less likely to have arteries and veins suitable for autogenous fistula (AF) formation in the classic location. Physical examination of the upper extremity alone may be inadequate for selection of arteries and veins that will mature into a functioning AF. The authors have used duplex ultrasound (DU) to assess upper-extremity vasculature for planning of dialysis access procedures. Criteria for selection of arteries and veins and a detailed description of our DU examination protocol are reviewed. Routine use of upper-extremity DU has identified many patients with forearm veins that are suitable for use, but in locations remote from the optimal arterial inflow or too deep to facilitate easy needle cannulation. Modifications to the single-incision radiocephalic fistula that allow for expanded use of forearm veins identified by DU are described, and the technique of superficial venous transposition of forearm veins in particular is reviewed in detail. On the basis of our experience, we recommend the combination of upper-extremity planning DU and superficial venous transposition in the forearm to increase use of AF and reduce reliance on prosthetic bridging grafts (BG) in patients requiring access for hemodialysis. Copyright (C) 2000 by W.B. Saunders Company.