Venous Mapping Prior to AVF

With Chronic Thrombosis

Patients entering their final stage of Renal Failure are in need of hemodialysis. In order
for surgeons to create arterial to venous fistulas for dialysis the patient must first have an
ultrasound to map out the veins in order to decide what the most optimal vessels are in which
arm. Superficial vein thrombosis can be a huge factor in placement of an arteriovenous fistula
because it eliminates available veins to use. In this case we see superficial chronic thrombosis in
a venous mapping exam.
A 56 year old male came into the vascular lab with end stage renal disease. He was
currently on dialysis using a right side permacath. He took medication for hypertension and high
cholesterol. He came in to get an ultrasound to map out usable veins and arteries for placement
of an arteriovenous fistula. Patient had no pain in either arm.
The test was started by taking waveforms and velocities of Radial and Ulnar arteries in
both arms using
Continuous Wave
Doppler and a size 10
blood pressure cuff on
the forearm. The arteries
showed to be
nonstenotic and of good
amplitude with a
biphasic component.
Velocities measured as
followed: 98mmhg
Right Radial Artery,
100mmhg Right Ulnar
Artery, 86mmhg Left
Radial Artery,
108mmhg Left Ulnar Artery (Image 1 shows
waveforms).Ultrasound duplex was then used to map out
central and superficial veins in the both arms. The patient
was put in a slight trendelenburg (image 2) position in
order to get maximum diameter for central veins. The
diameter was measured in a transverse plane using a 12-5
linear transducer in grayscale. A dual image was also taken to prove that the vessel did not have
thrombosis. Saggital view using color and spectral Doppler were also used to show waveforms,
Image 1, Arterial Waveforms
Image 2
Image 2
color filling and directionality. Image 3 shows Right IJV with diameter measurements and dual
screen compression. As you can see the vein fully compressed and was at optimal size over 1cm.
Duplex showed correct colorful and a respiratory phasic waveform (image 4).








The central veins scanned were Internal Jugular Vein, Subclavian Vein, Axillary Vein on
the chest inferior to the clavicle and Axillary Vein in the Axilla. Diameter of left Axillary Vein
on chest was measured in a saggital view and compressions were not taken in left Subclavian
Vein and Axillary Veins on the chest. Right Subclavian Vein was inaccessible due to dialysis
permacath.
Patient was then put into an erect position at a 45 degree angle. A tourniquet was used
high on the arm in order to get maximum diameter for superficial vessel. Dual screen
compressions with diameters were taken in the Cephalic and Basilic Vein. Measured locations
consisted of the following: Proximal Cephalic upper arm, Distal Cephalic upper arm, Cephalic at
Elbow, Proximal Cephalic forearm, Distal Cephalic forearm, Cephalic at wrist, High Basilic
upper arm, Mid Basilic upper arm, Basilic above confluence, Elbow Anterior Basilic Branch,
Elbow Posterior Basilic Branch, Basilic forearm.
When scanning the left Basilic Vein there
was a chronic thrombosis found in right above
the elbow in Basilic Vein. The vein was partially
compressible and had echogenic thrombus
within, which can be seen in image 5. In a
saggital view you can see the echogenic
thrombus shown in image 6. The arrows point
out the thrombus and the incompressible vein in
image 7. Thrombus eliminates that vein from the
ability to be used for an Arteriovenous Fistula.
Image 3
Image 3, arrow showing fully compressed vein Image 4
Image 6
These kinds of findings are necessary information for surgeons in order to have an optimal
Arteriovenous Fistula that works successfully for hemodialysis.













The rest of the left arm veins were compressible as were the right arm veins. All the necessary
information was collected from the ultrasound to create an interpretation for the physician.
The outcomes of the exam concluded that the central veins were optimum bilaterally, the
right arm Cephalic Vein was optimal but the forearm Cephalic were marginal. The Basilic Vein
in the right arm was marginal and the Left Basilic Vein was inadequate because of chronic
disease. The decision was to create a brachiocephalic arteriovenous fistula in the right arm.
In this case being able to correctly identify pathology can help to determine the best
possible outcomes for the patient. Thrombosis within the vein makes the vessel inadequate for
arteriovenous fistula formation. With the help of a sonographers keen eye and physician
knowledge we can provide the best care to the patient.
Image 7