Change Concept 3
Early referral to surgeon for "AVF only" evaluation and timely placement
- Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery referral.
- Nephrologist refers for vessel mapping where feasible, prior to surgery referral.
- Nephrologist refers patients to surgeons for "AVF only" evaluation, no later than Stage 4 CKD (GFR<30). Surgery scheduled with sufficient lead-time for AVF maturation.
- Nephrologist defines AVF expectations to surgeon, including vessel mapping (if not already performed).
- If timely placement of AVF does not occur, nephrologist ensures that patient receives AVF evaluation and placement at the time of initial hospitalization for temporary access (e.g. catheter).
When possible, coordinate chronic kidney disease patient care so that patients will be referred early to surgeons specifically for AV fistula evaluation, including vein mapping where indicated, allowing sufficient lead-time for AV fistula maturation. Studies show that mapping vessels can significantly increase the incidence of successful AV fistulae. Establish the understanding with your surgeons that they will contact you before placing anything other than an AV fistula. Where timing is such that a temporary access must be placed (e.g., catheter), arrange for evaluation (and placement, if feasible) of an AV fistula during the initial hospitalization.
Changes for Improvement:
Refer Patients for Vessel Mapping
Nephrologists should refer patients for vessel mapping (identification of vessel anatomy) where feasible, ideally prior to surgery referral. Doppler ultrasound or alternate technique should be used to search for suitable vessels that may be too deep to be identified on physical exam. Numerous studies have shown that vessel mapping identifies vessels suitable for an AV fistula in the majority of patients where physical exam alone classified the patient as not being a candidate for an AV fistula.
Schedule Surgery with Sufficient Lead-Time for AVF Maturation
In order to schedule surgery with sufficient lead-time for AV fistula maturation, nephrologists should refer patients to surgeons for "AVF only" evaluation no later than Stage 4 CKD (GFR<30).
Communicate AVF Expectations (including Vessel Mapping) to Surgeons
Nephrologists should establish an understanding with surgeons that all patients should be fully evaluated for the possibility of an AV fistula, including vessel mapping where necessary.
Related Tools
Revised 09/09
From: National Vacular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA
This form can be used by nephrologists to refer a patient needing a new hemodialysis access to a vascular access surgeon. The nephrologist can request the site preference for the desired access on the form, and the surgeon is requested to notify the nephrologist if the preferred access will not be placed.
This form from the Society for Vascular Ultrasound provides the procedure for vessel mapping.
From: Olympic Vascular Lab, Surgical Associates, and Memorial Nephrlogy Associates
Olympia, Washington, USA
Revised 09/09
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.