ACKD

Point-of-care Vascular Ultrasound: Of Fistulas

and Flows
Adina S. Voiculescu and Dirk M. Hentschel

Point-of-care ultrasound (POCUS) is increasingly being used in nephrology as a diagnostic tool, and there is a growing interest
among physicians and nursing staff to learn how to use POCUS for the evaluation of the dialysis vascular access (DVA). The goal
of POCUS is to extend the physical examination and more closely evaluate the DVA at bedside. Typically, POCUS quickly
answers yes-no questions (ie, Is the vein too deep? Y/N). It is not the goal of POCUS of the vascular access to extensively
investigate the entire fistula or graft. In conjunction with a good physical examination, brightness-mode ultrasound alone
can answer most questions regarding the DVA, such as depth and diameter of the vessel. With some additional training, a
limited color Doppler can be added to the standard evaluation to check flow direction and pseudoaneurysms. With more
extensive training and an understanding of Doppler physics, access flow volumes can also be determined using spectral
Doppler-mode ultrasound.
Q 2021 by the National Kidney Foundation, Inc. All rights reserved.
Key Words: Ultrasound, Doppler ultrasound, Point-of-care, Dialysis vascular access, Arteriovenous fistula

Duplex ultrasound5; however, these are aimed at vascular

P oint-of-care ultrasound (POCUS) is increasingly being
used in medicine and its subspecialties.1 Nephrology
practitioners have recently shown increased interest in
acquiring the necessary POCUS skills including the
evaluation of the dialysis vascular access (DVA).2,3 POCUS
is an attractive tool because it is universally available,
noninvasive, nontoxic, portable, and easily repeatable.1
The goal of POCUS is to confirm and extend the DVA
physical examination as well as allow real-time
troubleshooting at the bedside. POCUS is an excellent
tool for answering yes/no questions, ie, is the vessel too
deep? It is not the goal of DVA POCUS to extensively
investigate every possible characteristic of a given fistula
or graft. These distinctions need to be kept in mind when
setting trainee expectations and establishing rules and
standards for teaching and competency.
The objective of this article is to first describe the
necessary knowledge base of nomenclature for the DVA,
followed by a discussion of a thorough physical
examination of the DVA combined with the proper
technique of POCUS, and finally, a list of common
applications of POCUS in a clinical setting.
CURRENT STATE
At present, POCUS of the DVA is neither commonly
performed nor is it standardized for nephrology staff.
Typically, nonnephrologists and vascular laboratory
technologists perform ultrasound studies of the DVA
using guidelines published by The American Institute of
Ultrasound in Medicine.4 This recommended examination
format is complex and time-consuming and requires
extensive training. Despite these guidelines, even when
performed by expert vascular laboratories, data acquisi-
tion and its presentation and interpretation remain highly
variable. One reason for this is that the nonnephrologists
or technologists perform DVA examinations usually
without practical knowledge of how DVAs are used in
dialysis units, what surgical or endovascular procedures
have been performed or are possible, and what cardiovas-
cular consequences DVAs carry for individual patient’s
health. Experts in vascular access creation have published
detailed protocols for dialysis access evaluation with
surgeons or interventionalists.
Nephrologists, dialysis nurses, and technicians, and as a
result, their patients in clinic or the dialysis unit, would
likely gain the greatest benefit from DVA POCUS training.
However, practitioners often do not have the skills or spe-
cific ultrasound technical training to support and enhance
the examination of the DVA.
WHAT ARE THE PREREQUISITES FOR POCUS FOR
FISTULAS AND FLOW?
Nomenclature
The first step is to be able to recognize and properly name
the DVA using a standardized nomenclature for the
dialysis access. According to the Society of Vascular
Surgery guidelines, arterio-venous-fistulas and arterio-
venous-grafts are named according to site of use (right/
left, forearm/upper arm/thigh/chest-wall), the inflow artery
used for arterial anastomosis (radial, brachial), the named
vein used for the anastomosis (cephalic, basilic), and the indi-
cator differentiating between an autogenous or a prosthetic
access6 (Table 1). Figure 1 depicts the most common types
of access.
Step 2 is to use the same description of the access in terms
of functional areas. The access circuit has an access inflow,
the “stick zone” for needle insertions, and an access outflow
(Fig 2). The access inflow encompasses the inflow arteries,
the juxta-anastomotic segment, and an inflow segment of
varying lengths between the juxta-anastomotic area and
From the Renal Division, Brigham and Women’s Hospital, Boston, MA.
Financial Disclosure: A. S. Voiculescu is a consultant for Clinlogix. D. M.
Hentschel is a consultant for Bard-BD, Biosurfaces, BluegrassVascular, Elipsys,
Laminate, Medtronic, Merit, MinnHealth, Sanfit.
Address correspondence to Adina S. Voiculescu, MD, FASDIN, Assistant
Professor Harvard Medical School, Renal Division Brigham and Women’s Hos-
pital, Director of Ultrasound in Nephrology, Brigham and Women’s Faulkner
Hospital, 1153 Centre Street, Suite 4G Boston, MA 02130. E-mail:
avoiculescu@bwh.harvard.edu
Ó 2021 by the National Kidney Foundation, Inc. All rights reserved.
1548-5595/$36.00
https://doi.org/10.1053/j.ackd.2021.07.003

Adv Chronic Kidney Dis. 2021;28(3):227-235 227

228 Voiculescu and Hentschel

the visibly used needle-insertion segment. The “stick spectral Doppler may not be available on hand-held
zone” can also be described as the body of the access and devices. In addition, the Doppler feature needs to include
has an arterial needle and venous needle insertion area. flow volume calculation software.
The venous outflow encompasses peripheral and central
veins leading to the right atrium. Training in Access Ultrasound
POCUS evaluation of the access is focused on the As with any technical skill, adequate training and prac-
“stick-zone” and determines depth, diameter, and the tice are a prerequisite. It is key to establish a compre-
location of side branches. Flow determination requires hensive curriculum and enforce rigorous training
an additional evaluation of the inflow artery or a common criteria for the POCUS novice to ensure the resulting
single outflow vein segment. benefits for patients. This would include didactic
training in principles of ultrasound and hands-on prac-
Physical Examination tice performing the particular examination. In addition,
The final step before performing a POCUS is a standard- knowledge and application of standardized documen-
ized physical examination of the DVA.7 This standardized tation, image storage, and report writing are equally
physical examination described in the literature includes important. A total of 50-100 training studies are often
evaluating the following 5 criteria: thrill, bruit, pulsatility, necessary to allow for competent and independent ul-
augmentation, and the collapse of the vein during arm trasound evaluation of the DVA. These studies should
elevation.8 The mastering of this comprehensive physical include B-Mode images of the body of the access with
examination enables the understanding of flow, pressure, measurement of depth and diameter. They should
and difficulties that could arise during needle cannulation. note if side-branches/hematomas are present and
Table 2 shows the 5 key elements of the physical should measure access flow volumes in the brachial
examination with a description of a normal and abnormal artery.
examination. The absence of To date, most training
a bruit and thrill will typi- programs for vascular tech-
CLINICAL SUMMARY
cally be sufficient to deter- nologist apply criteria of
mine that an access is the American Institute of

Point-of-care ultrasound for the nephrologist should
completely thrombosed. Ultrasound in Medicine.4
include dialysis vascular access (DVA) evaluation.
Increased pulsatility, with Currently, the American
no collapse of the body of
Training includes mastering the correct nomenclature of
Society of Diagnostic and
the access, indicates a likely the DVA and proper physical examination technique.
Interventional Nephrology
outflow obstruction. Poor
Brightness-mode (with black and white images) ultrasound is taking the lead in outlining
augmentation with absent allows for evaluation of depth and diameter of the vessel as criteria for vascular access
pulsatility indicates a likely well as evaluation for extravasations and can be a guide for ultrasound training and
inflow obstruction. Different cannulation of the access. certification in the use of
types of accesses are predis- ultrasound throughout

Spectral Doppler-mode, although requiring more training
posed to certain locations of and sufficient understanding of ultrasound physics, en- nephrology. These certifica-
stenoses as upper arm access ables reliable flow volume measurements which adds tion guidelines are presently
and grafts often have essential information to the overall DVA evaluation. under development.
outflow obstructions and
forearm fistulas most often
have inflow problems.9 ACCESS ULTRASOUND
In short, outflow stenoses will increase the intra-access Ultrasound evaluation has been shown to be helpful in
pressure with increased bleeding propensity, infiltrations, determining clinical maturation of the DVA while looking
and high venous pressure alarms while on the dialysis at diameter, depth, and flow volumes at 2 and 6 weeks
machine. Inflow stenoses are associated with difficult after a newly created access.10-12 A DVA is considered
needle placement, arterial needle alarms, or collapse of usable if the body of the access has a diameter of 4-6 mm
the access around the venous needle. Inflow and outflow and a depth of less than 5-6 mm, and the access has a
stenoses may decrease the overall access flow; therefore, flow volume of .500-600 mL/min.10,13 In our experience,
measurement of flow volume alone does not allow one the rule of 6 (,6 mm depth, .6 mm diameter, and
to determine where a stenosis is located. .600 mL/min flow) for defining access maturation is
easier to remember and obtains better results in dialysis
What Instruments Are Needed? units.
Ultrasound machines of any size, equipped with a To date, vascular laboratories or radiology departments
high-frequency probe (7.5-12 MHz) are required. have been responsible for performing maturation studies
Brightness-mode (B-Mode) ultrasound is standard on of the DVA, but with proper training, nephrology
any machine including hand-held ultrasound devices. practitioners can obtain the same parameters at the
For the utilization of Doppler, one has to differentiate bedside or in the office using POCUS. It is important to
between color Doppler and spectral Doppler. While color note that several additional questions can also be
Doppler is available on nearly all types of machines, answered using ultrasound at the bedside. Table 3 lists

Adv Chronic Kidney Dis. 2021;28(3):227-235

 Dialysis Access Ultrasound 229

Table 1. Nomenclature of Dialysis Accesses

Type of Access Forearm Upper Arm
Autogenous access Radial-cephalic access (Snuff-box, Brachial-cephalic fistula
Cimino, RADAR) Transposed brachial-basilic fistula
Transposed ulnar-basilic (rare) Transposed brachial-brachial fistula (rare)
Proximal radial—perforans fistula (Gracz or Endo-arterio-venous fistula)
Proximal radial-cephalic bidirectional (Jennings) fistula
Prosthetic access Radial-cubital median/cephalic/basilic/ Brachial—axillary straight or loop graft
brachial straight graft Axillary-axillary loop graft
Brachial-cubital medial/cephalic/basilic/ Axillary-brachial loop graft (reverse)
brachial forearm loop graft

Abbreviation: RADAR ¼ radial artery deviation and reimplantation (surgical technique for radial-cephalic autogenous access creation).

many of the questions, which may be addressed with
POCUS applications.
Technical Aspects of Performing POCUS of DVA
Rest the patient’s arm comfortably on a pillow. Before
beginning any DVA ultrasound study, it is of utmost
importance to apply a liberal amount of ultrasound gel to
the region of interest. Without adequate gel, the trans-
mission of ultrasound waves, and therefore the image
acquisition, will be incomplete. In addition, it is important
not to apply too much pressure with the ultrasound probe.
B-Mode Ultrasound
POCUS with B-Mode allows for a visual map of the DVA. It
helps identify straight and curved sections. A transverse
and longitudinal evaluation with B-Mode helps to
determine if an access vein or graft is accessible with
needles. If the vessel in the body of the access is at more
than 5- to 6-mm depth, cannulation will be difficult or
impossible. Figure 3 demonstrates a vessel that is sufficient
in size and at appropriate depth for cannulation. If the
vessel is not 5- to 6-mm wide, it will be difficult to
cannulate without significant trauma and usually
indicates that the access does not have the right flow and
pressure balance.
Tributary veins, known as side branches, can divert flow
from the main access vein and can be a cause for poor
augmentation observed during the physical examination.
Side branches can occur in the presence and in the absence
of stenoses of the access vein. In this situation, side
branches can be located by performing a transverse sweep
(sweeping of the ultrasound probe from the inflow to the

Figure 1. Images of the most frequent types of accesses. (A) Left forearm radial-cephalic autogenous access. (B) Left upper
arm brachial-cephalic autogenous access. (C) Right upper arm transposed brachial-basilic autogenous access. (D) Left
forearm brachial-cephalic loop prosthetic access. (E) Left upper arm brachial axillary loop prosthetic access.
Adv Chronic Kidney Dis. 2021;28(3):227-235
230 Voiculescu and Hentschel

Table 3. Appropriate Questions for Dialysis Vascular Access

Figure 2. Left forearm radial-cephalic autogenous access
with anastomosis at the “snuff-box”. Access with marking
of inflow, stick-zone or body of the access, and outflow.
outflow) over the access and subsequently drawn with a
marker on the skin (Fig 4). A fascia overlying the vein
can be another cause of poor augmentation and is again
detectable using B-Mode ultrasound (Fig 4).
Difficulty with cannulation in a patent access can be
caused by a partially occluding thrombus. Thrombi are
seen as echogenic, intraluminal filling defects.
Any abnormal findings after a proper physical examina-
tion and POCUS should help determine whether a fistulo-
gram with intervention (treating inflow or outflow
stenosis) or vascular access surgery (superficialization of
the vein, fasciotomy, or side-branch ligation) is required
to make the DVA functional.
Using ultrasound as guidance for cannulation is another
highly useful application of POCUS. In the dialysis center,
bedside ultrasound can be used to mark the arm for needle
insertion. Alternatively, the needle can be inserted using
real-time ultrasound.14,15 Protocols using ultrasound-
guided cannulations have been developed in several cen-
ters.16,17 Ultrasound-guided cannulation is particularly
useful in low-flow, low-pressure accesses and fistulas
with multiple outflow veins, a situation that is often
encountered in percutaneously created arteriovenous
fistulas.
Occasionally, there is a lump or swelling over the access
that requires evaluation and interpretation. Ultrasound
can help determine whether the swelling is due to a
dilation of the vein (aneurysm or pseudoaneurysm) or if
there is a seroma, hematoma, or abscess overlying the
access (Fig 5). Table 4 describes the ultrasonography
POCUS
Questions
B-Mode
Diameter of access vein in needle insertion segment
(body of access)
Depth of access vein for needle insertion (body of access)
Presence and location of side-branches (yes/no)
Presence of extravasation/aneurysm/pseudo-aneurysm/fluid
collection (yes/no)
Presence of thrombus—partial or complete (yes/no)
Guidance for needle insertion
Color-mode
Direction of flow
Differentiate between hematoma vs pseudo-aneurysm
(yes/no)
Doppler (spectral) mode
Flow volume measurement
Abbreviation: POCUS ¼ point-of-care ultrasound.
appearance of commonly seen dialysis access–related
pathologies.
Partial and complete thrombosis of the access are seen as
hypoechoic material within the lumen of the vein or graft.
Color-Mode Ultrasound
The application of color-mode Doppler (C-Mode) can be
used to determine the presence and the direction of flow.
As a general rule, flow moving toward the transducer
will be coded red, and flow away from the transducer
will be coded blue. For POCUS, it is best to limit the use
of C-Mode as a tool to help answer simple questions,
and not to map the entire access. While the physical
examination alone can reveal that there is flow, the
addition of color can be helpful to determine flow into a
structure not related to the access, ie, pseudoaneurysm
or continuous bleeding into the tissues (Fig 6).
Spectral Doppler Ultrasound
Spectral Doppler (D-Mode) allows for the measuring of
flow velocities over time in a specific location and depicts

Table 2. Physical Examination Components for Normal and Dysfunctional Dialysis Accesses
Exam Component
Thrill
Bruit
Pulsatility (feel at body of access)
Augmentation (pulsatility while
occluding outflow)
Collapse with arm elevation
(observe at body of access
while elevating arm over
the heart level)
Normal
Continuous (juxta-anastomotic)
Continuous (inflow/body)
Normal
Normal
Complete (forearm fistula)
Partial (upper arm fistula)
(This does not apply to grafts.)
Outflow Stenosis Inflow Stenosis
Continuous (@stenosis) Discontinuous*
Discontinuous* (juxta-anastomotic)
(juxta-anastomotic)
Continuous/Discontinuous* Continuous/Discontinuous*
High pitch @stenosis High pitch @stenosis
Increased (retrograde Decreased (antegrade to stenosis)
to stenosis)
Normal Weak
No collapse retrograde Complete antegrade to stenosis
to stenosis

*Depends on flow volume of the access. Bruit becomes discontinuous with lower flow volumes.

Adv Chronic Kidney Dis. 2021;28(3):227-235

 Dialysis Access Ultrasound 231

Figure 3. Ultrasound images of a forearm radial-cephalic access showing a transverse and longitudinal view of the body of
the access with depth and diameter determination. Access vein and depth are adequate for needle insertion.

them in graph form. While B- and C-Mode ultrasound are
relatively easy to learn, several additional steps need to be
mastered to correctly apply spectral Doppler.
Spectral Doppler is required for flow volume determina-
tion. Timed average mean flow velocities (TAMVs) in a
vessel as well as the diameter of the vessel for calculation
of the area are the parameters needed for the flow volume
calculation. TAMV needs to be obtained over several pulse
cycles. The area of the vessel is calculated after measuring
the diameter of the vessel.
The following formula is used to measure flow volumes.
Flow volume in ml/min ¼ Mean velocity (TAMV) (cm/sec)
3 Area (cm2) 3 60 (sec) This formula is preprogramed in
ultrasound machines. Special attention is needed to make
sure that the software is present and the settings are
correct.
To obtain accurate flow volume measurements in a
vessel, several rules need to be strictly applied (Table 5).
With the understanding that only a straight vessel with
nonturbulent flow allows for correct flow measurement, it
is best to measure access flow volumes in the brachial artery close
to the elbow or in a singular outflow vein as opposed to the “stick
zone”.10,12,18,19 Too often, the body of the access is tortuous
and has varying diameters, and the flow is turbulent,
resulting in inaccurate measurements. Also, it is of utmost
importance to measure flow velocities at the proper angle

Figure 4. Right forearm radial-cephalic autogenous access with poor augmentation. Ultrasound images demonstrate several
side-branches, which were then marked on the skin for planning of side-branch ligation as well as a fascia overlying the
vessel, which may require fasciotomy. At the level of the fascia, the depth is marginal for needle insertion and may need
additional tissue-removal (lipectomy) to make the vessel more accessible.

Adv Chronic Kidney Dis. 2021;28(3):227-235

232 Voiculescu and Hentschel

Figure 5. Left upper arm brachial-cephalic autogenous access, which suffered infiltrations. The B-Mode ultrasound
demonstrates that the vein is now at considerable depth, and a hematoma is overlying the vein. The diameter of the access
vein is sufficient. A map on the arm after evaluation of the depth can help with needle insertion.

(,60o), which is often impossible in a superficial vessel,
such as the body of the access or the radial artery. Only a
few studies compare the accuracy of ultrasound flow
measurement with both the brachial artery and outflow
vein with that of invasive flow measurement.20 Figure 7
demonstrates the correct location for measuring flow
volume in the brachial artery in a patient with a left
forearm radial-cephalic autogenous access. Figure 8
demonstrates the images and measurements obtained for
flow volume determination.
DVA flow volumes can be highly variable. Flow volumes
can range from 200 to .3000 mL/min. The critical flow
volume of an autogenous access has been determined to
be around 400 mL/min. In a prosthetic access, the critical
flow volume is approximately 600 mL/min.21,22 A fistula
with a flow volume below 400 mL/min will not sustain
efficient dialysis at pump speeds of 350-400 mL/min, and
a graft with a flow volume below 600 mL/min is at risk
for thrombosis. In the event where serial flow volume
measurements are performed, a decrease in flow volume
of more than 25% over 4 months points toward access
dysfunction.10
Sometimes, DVA can have too much flow, ie, greater than
1.5 or 2 L/min. High flow puts the access at risk of bleeding,
and high pressures, vein dilation with aneurysm
formation. Patients with high flow are at risk to develop
steal symptoms and/or heart failure. With diagnosis of
high flow, it may be best to refer the patient for expert
evaluation and possible treatment with flow reduction,
ie, precision banding.23
What Measurements Should Not Be Attempted with
POCUS
Spectral Doppler utilization for measurement of flow
velocities and determination of stenosis of the DVA is
difficult because of the aforementioned reasons, and the
values are difficult to interpret. They also have limited
clinical use. Therefore, measurement of flow velocities
along the entire circuit is not recommended to be a
standard for nonexpert vascular sonographers.

Table 4. Ultrasonographic Appearance of Commonly Seen Pathologies Associated With the Dialysis Access
Pathology Sonographic Appearance of Access-Related Pathologies
Seroma An-echoic round structure
Hematoma Hypoechoic/echo inhomogenous structure around the access vein
Abscess Hypoechoic/echo inhomogenous structure similar to a hematoma but with additional clinical signs of infection
Aneurysm Dilated segment of the access vein
Pseudoaneurysm Out pouching of the vessel with a pulsatile flow that appears on color and spectral Doppler
Tissue edema Cobblestoning pattern

Adv Chronic Kidney Dis. 2021;28(3):227-235

 Dialysis Access Ultrasound 233

Figure 6. Left upper arm brachial-cephalic access with “lump” and difficulties in needle insertion. B-Mode demonstrates
partially occluding thrombus with patent vessel underneath. The addition of color Doppler demonstrates continuous flow
into this partially thrombosed pseudoaneurysm.

Table 5. Step-by-Step Instruction for the Spectral Doppler Use for

Flow Volume Measurements
Dialysis Access Flow Volume Measurement
1) Measure in a region of straight, nontapering, nonturbulent
flow (brachial artery at elbow or outflow vein at noncom-
pressible site).
2) Start D-Mode (do not use C-Mode).
3) The Doppler gate is to be placed in the middle of the vessel.
4) Adjust the angle of the incoming ultrasound waves using the
steering function.
5) Adjust gate to encompass at least 75% to 100% of the vessel
lumen.
6) Adjust the caliper for the angle correction to be parallel to the
vessel (angle between incoming ultrasound wave and
vessel , 60 ).
7) Start the spectral Doppler to obtain timed average flow
velocities.
8) Freeze image and Doppler and press Calculator.
9) Time averaged mean velocity (TAMV) not time average peak
velocities need to be preprogramed in calculation of flow
volume.
10) TAMV should be determined over a sequence of 3-4 cardiac
cycles.
11) The diameter of the vessel is measured perpendicular and
with caution of not compressing the vessel.
12) TAMV and diameter will allow the calculation the flow
volume.
13) Obtain 2-3 measurements to ensure accuracy and average.
14) Document flow volume in conjunction with blood pressure
measured at the same time.
POSSIBLE SCENARIOS FOR POCUS OF THE DVA
Access Ultrasound Immediately After Creation of a
DVA, Before Utilization
After creation, a DVA should be carefully examined for
patency and maturation. The 5 points of the physical
examination can determine if there is any flow, if there
is sufficient augmentation, and if there is an outflow
problem.
As long as there is bruit and thrill, the access is patent. If
the vein itself is not well palpable and there is weak
augmentation, POCUS can help determine depth, size,
and presence of side branches or an overlying fascia. The
additional measurement of flow volumes in the brachial
artery will add pertinent information. A flow of less than
500-600 mL/min at 6 weeks after creation will require
expert evaluation for further management.24
Access Ultrasound During DVA Utilization
Difficulty in Cannulation. POCUS can be used to check
the diameter and depth of the access, which may have
changed because of an infiltration. If the access is generally
to deep, then the use of B-Mode for real-time needle
insertion is another possible scenario.
Additional flow volume measurement can help deter-
mine if the flows are too low or have decreased over time.
Lumps or Swelling Over the Access. Lumps or swelling
over the access are frequent pathologies detected during
dialysis. In these situations, the DVA can be assessed

Adv Chronic Kidney Dis. 2021;28(3):227-235

234 Voiculescu and Hentschel

Figure 7. (A) Left forearm radial cephalic autogenous access, which is superficial and tortuous. (B) and (C) demonstrate the
difficulty to place the probe on the access. There is no area on the access vein allowing correct positioning. (D) The probe is
now placed at the elbow, evaluating the brachial artery. In this position, the vessel can be insonnated at an angle ,60 , and
compression of the vessel is less likely.

for pseudoaneurysms, hematoma, and extravasation with are considered to put patients at risk for steal or congestive
B- and C-Modes. heart failure.

Heart Failure or Steal Symptoms. Access flow volume SUMMARY AND CONCLUSIONS
measurement can help diagnose a high-flow access. Even POCUS represents a very valuable extension of the DVA
though there is no standard definition of high flow, physical examination. It is portable, noninvasive, easily
generally flow volumes greater than 1500-2000 mL/min repeatable, and can be performed efficiently at bedside

Figure 8. (A) B-Mode image of the brachial artery demonstrating the direction of ultrasound waves as compared to the artery
and (B) the spectral Doppler for flow volume determination using the diameter and timed average mean velocities (TAMV)
over several heart cycles.

Adv Chronic Kidney Dis. 2021;28(3):227-235

 Dialysis Access Ultrasound
by trained nephrology staff. Although the training may
take several weeks, the trainee is more than compensated
by the immediate availability of pertinent information
describing the DVA and the resulting diagnosis based on
the added data and the vascular visualization. Mastering
B- and C-Mode ultrasound in conjunction with the skills
for performing a detailed physical examination should
be the first recommended steps for the novice ultrasono-
grapher. More extensive training in the use of spectral
Doppler is highly recommended for a more comprehen-
sive understanding of the DVA. Ultimately, the use of
POCUS by nephrology staff is of great benefit to them as
well as to the patient and their access-related issues.
ACKNOWLEDGMENTS
The authors thank David Binder for his careful review and
editing of the manuscript.
REFERENCES
1. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med.
2011;364(8):749-757.
2. Koratala A, Teodorescu V, Niyyar VD. The nephrologist as an ultra-
sonographer. Adv Chronic Kidney Dis. 2020;27(3):243-252.
3. Niyyar VD, O’Neill WC. Point-of-care ultrasound in the practice of
nephrology. Kidney Int. 2018;93(5):1052-1059.
4. AIUM practice guideline for the performance of a vascular ultra-
sound examination for Postoperative. Assess Dial Access.
2014;33:1321-1332.
5. Teodorescu V, Gustavson S, Schanzer H. Duplex ultrasound evalua-
tion of hemodialysis access: a detailed protocol. Int J Nephrol.
2012;2012:508956-508962.
6. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for
reports dealing with arteriovenous hemodialysis accesses. J Vasc
Surg. 2002;35(3):603-610.
7. Salman L, Beathard G. Interventional nephrology: physical exami-
nation as a tool for surveillance for the hemodialysis arteriovenous
access. Clin J Am Soc Nephrol. 2013;8(7):1220-1227.
8. Hentschel DM. Hemodialysis vascular access Maintenance and
Salvage. In: Darlin RC, Ozaki K, eds. Master Technique in Surgery.
Chicago/Turabian: Lipincott Williams & Wilkins; 2015:1-17.
9. Turmel-Rodrigues L, Pengloan J, Baudin S, et al. Treatment of
stenosis and thrombosis in haemodialysis fistulas and grafts by
interventional radiology. Nephrol Dial Transplant. 2000;15(12):2029-
2036.
Adv Chronic Kidney Dis. 2021;28(3):227-235
235
10. Vascular Access 2006 Work Group. Clinical practice guidelines for
vascular access. Am J Kidney Dis. 2006;48(Suppl 1):S176-S247.
https://doi.org/10.1053/j.ajkd.2006.04.029.
11. Robbin ML, Chamberlain NE, Lockhart ME, et al. Hemodialysis
arteriovenous fistula maturity: US evaluation. Radiology.
2002;225(1):59-64.
12. Robbin ML, Greene T, Allon M, et al. Prediction of arteriovenous fis-
tula clinical maturation from Postoperative ultrasound measure-
ments: findings from the hemodialysis fistula maturation study. J
Am Soc Nephrol. 2018;29(11):2735-2744.
13. Lok CE, Huber TS, Lee T, et al. KDOQI clinical practice guideline for
vascular access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164.
14. Marticorena RM, Mills L, Sutherland K, et al. Development of compe-
tencies for the use of bedside ultrasound for assessment and cannula-
tion of hemodialysis vascular access. CANNT J. 2015;25(4):28-32.
15. Schoch M, Bennett PN, Currey J, et al. Point-of-care ultrasound use
for vascular access assessment and cannulation in hemodialysis: a
scoping review. Semin Dial. 2020;33(5):355-368.
16. Niyyar VD. Ultrasound-based simulation for cannulation in outpa-
tient hemodialysis units: an educational protocol. J Vasc Access.
2019:585-589:1129729819891530.
17. Ward F, Faratro R, McQuillan RF. Ultrasound-guided cannulation of
the hemodialysis arteriovenous access. Semin Dial. 2017;30(4):319-325.
18. Ko SH, Bandyk DF, Hodgkiss-Harlow KD, et al. Estimation of
brachial artery volume flow by duplex ultrasound imaging predicts
dialysis access maturation. J Vasc Surg. 2015;61(6):1521-1527.
19. Zamboli P, Fiorini F, D’Amelio A, et al. Color Doppler ultrasound
and arteriovenous fistulas for hemodialysis. J Ultrasound.
2014;17(4):253-263.
20. Bergmann MH, Hentschel DM, Toegel F, McMullan C, Voiculescu A.
Measuring Access Blood Flow with Doppler: where should we mea-
sure? A cohort study comparing flow in the Brachial Artery and the
Outflow Vein with invasive measurement with angioflow meter. J
Vasc Access. 2017;18(5):e84.
21. Bay WH, Henry ML, Lazarus JM, et al. Predicting hemodialysis ac-
cess failure with color flow Doppler ultrasound. Am J Nephrol.
1998;18(4):296-304.
22. Besarab A, Lubkowski T, Frinak S, et al. Detecting vascular access
dysfunction. ASAIO J. 1997;43(5):M539-M543.
23. Beathard GA, Jennings WC, Wasse H, et al. ASDIN white paper:
assessment and management of hemodialysis access-induced distal
ischemia by interventional nephrologists. J Vasc Access.
2020;21(5):543-553.
24. Lomonte C, Casucci F, Antonelli M, et al. Is there a place for duplex
screening of the brachial artery in the maturation of arteriovenous
fistulas? Semin Dial. 2005;18:243-246.