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International Journal of Advanced Computer Science, Vol. 1, No. 1, Pp. 16-22, Jul. 2011.

Manuscript
Received:
16, June, 2011
Revised:
1, July, 2011
Accepted:
25, July, 2011
Published:
10, August, 2011
Keywords
hemodialysis,
wavelet
transform,
arteriovenous
fistula.

Abstract According to the annual
statistics report of the United States Renal
Data System (USRDS) in 2009, the number
of patients with end-stage renal disease has
increased yearly, especially those patients
undergoing hemodialysis. As they require
long-term vascular punctures, and stenosis
easily occurs at puncture sites or vascular
junctions. The objective of help
hemodialysis patients to remove the noises
and to retain important features as much as
possible by identifying the features of
changes in blood flow frequency, and utilize
a digital signal processing technique and
wavelet transform algorithm in order to
determine arteriovenous fistula stenosis for
patients, with the goal of preventing, rather
than treating the disease. The proposed
method is using wavelets transform
algorithm of vessels sounds utilizing
characteristics extraction. The proposed
hard threshold wavelet decomposition at
multiple levels is a simple and facilitates
identification. Results suggested that this
technique can be useful.
1. Introduction
According to the statistical report of the United States
Renal Data System (USRDS), the number of end-stage renal
patients in Taiwan ranked first in the world in 2008.
Moreover, the incidence and prevalence rates are number
one in the world, higher than those of the US and Japan.
Clinically, there are three methods to treat renal disease,
namely, hemodialysis, peritoneal dialysis, and kidney
transplantation. Hemodialysis, which is the most common
treatment for patients with renal disease, uses a hemodialysis
machine to scavenge for waste in body, and thereby,
discharges excessive salt and potassium ion. According to
the statistics of the Taiwan Kidney Foundation, the number
of hemodialysis patients increases every year. A total of
57,844 patients with chronic renal failure receive long-term
dialysis, among which, 52,538 are hemodialysis patients
(90.83%), and 5,306 are peritoneal dialysis patients (9.17%).
As seen, hemodialysis patients account for an extremely high
percentage.
An arteriovenous fistula site must be first surgically

Yen-Nien Wang and Shi-Jun Chou are with Lunghwa University of
Science and Technology, Department of Electronic Engineering
(ynwang@mail.lhu.edu.tw; G972321012@ms.lhu.edu.tw)
Chih-Yang Chan is with National Taiwan University Hospital,
Department of Surgery(chanchihyang@hotmail.com)
created on the arms of hemodialysis patients, and can be
either an autogenous arteriovenous fistula or an artificial
fistula. Autogenous arteriovenous fistula is created by
vascular anastomoses when the patients arteries and veins
are in good condition; while artificial fistula applies to
patients with poor vascular condition, and an artificial blood
vessel serves as a bridge between the patients arm arteries
and veins. For long-term hemodialysis patient, it is very
important to maintain permanent vascular access patency in
order to achieve optimal dialysis effects. More than 80% of
hemodialysis patients have arteriovenous fistula embolism
due to blood stenosis at the puncture site. In particular,
patients using artificial vessels often have stenosis at
vascular junctions or puncture openings. Vascular stenosis
easily causes insufficient blood flow, which renders toxin
and water difficult to discharge, and may undermine or even
nullify hemodialysis.
Vascular stenosis is a kind of vascular disease, usually
due to trauma, high blood fat, or cholesterol. When blood
passes through the vascular stenosis site, vascular fat or
blood clots in the vessel reduce blood flow dynamics, thus,
leading to high venous pressure in hemodialysis, machine
out of range during treatments, insufficient blood flow, and
incomplete urine toxin removal. Severe stenosis leads to
embolism; where embolitic blood clots are likely to flow to
the heart, lungs, or brain. The situation may induce a
myocardial infarction, a pulmonary embolism, or a
cerebrovascular embolism, which could result in coma or
death. Conventional diagnosis of arteriovenous fistula
stenosis includes angiography and ultrasonic detection.
Angiography is a type of invasive precision examination,
where a contrast medium must be injected into a blood
vessel, which has high side effects. Ultrasonic detection is a
non-invasive technique with low side effects, and is used to
check for blood stream changes and size of vessel in order
to determine if the blood vessel has narrowed or is blocked.
Clinically, upon encountering vascular stenosis, a high tone
ejection murmur equal in diastolic and systolic periods will
occur, known as the Sea-gull Murmur, as its sound is mostly
a high-frequency signal, and sounds when the blood flow
meets with a resistance, which is presumably a feature of
vascular stenosis.
Vesquez proposed using the eigenvalue method to
determine signal differences. He found that anomalies occur
at 300~500 Hz, 200~800 Hz, and 250~1000 Hz [1], which
is a frequency with a wide range. This study significantly
shortens the range for stenosis to between 700 Hz~800 Hz
after signal processing. The proposed method is a
non-invasive, safe, rapid, and low cost technique, which
uses an electronic stethoscope to measure the blood flow
The Detection of Arteriovenous Fistula Stenosis for
Hemodialysis Based on Wavelet Transform
Yen-Nien Wang, Chih-Yang Chan, & Shi-Jun Chou
Wang et al.: The Detection of Arteriovenous Fistula Stenosis for Hemodialysis Based on Wavelet Transform
International Journal Publishers Group (IJPG)

17
sound signal, and utilizes a wavelet algorithm to analyze
vascular stenosis [2].
Conventional biomedical signal analysis is generally
composed of time domain and frequency domain analyses.
The time domain uses waveform width, height, and interval,
where the high-frequency signal analysis is applicable to a
small time interval, but is subjected to a pulse, and thus,
could only be used on a non-stationary signal. The
frequency domain adopts the Fourier Transform in order to
transform a time signal into a frequency domain, and then
observes the spectral signal, in order to determine the
significance of the physical signal [3]. The Fourier
Transform causes a linear superposition of the Harmonic
Function in the signal. In regard to a periodic signal, which
does not abruptly change with time, its signal characteristic
can be well exhibited from the spectra. However, the
periodic signal is not the most important in most cases; thus,
the non-periodic signal (e.g., signal feature point) is the key
focus of this study, specifically, when the Fourier
Transform shows its limitation and weak point by failing to
provide time dependent information [4]. Therefore, both
frequency and amplitude must be functions of time before
being able to demonstrate signal characteristics. Fourier
Transform adopts the square-integrable real function space,
to any function in space, Fourier Transform definition is:
( ) ( )
j t
F f t e dt
e
e
+

=
}
(Equ. 1)
1
( ) ( )
2
j t
f t F e d
e
e e
t
+

=
}
(Equ. 2)
where
j t
e
e
is the base value of square-integrable real
function space ) (
2
R L , when frequencye adopts discrete
integer n e = , here is Fourier series base value,
jnt
e .
Although
j t
e
e
is a frequency-dependent continuous form
of
jnt
e , they differ greatly. First, the function space
) (
2
R L differs completely from ) 2 , 0 (
2
t L ; second,
) (
2
R L must attenuate to zero when each function is
infinitely great. Unlike the continuous and discrete forms of
a wavelet transform, the Fourier Transform cannot provide
uniform descriptions. The Fourier Transform discrete form
is:
( ) ( )
jn t
F n f t e dt
+
A

A =
}
(Equ. 3)
where discrete the Fourier Transform is a function with
period of 2 / t A , and can be seen beyond function
space ) (
2
R L . The best way to search an ) (
2
R L wave, in
order to generate the entire function space ) (
2
R L , is to
retain waveform and move along R, such a wave is called a
wavelet. The wavelet theory is an analytical method
developed over the past decade, and was first used to
analyze electromagnetic waves, seismic waves, and
quantum physics. At present, wavelet analysis has been
successfully applied in many biomedical research
techniques, as it can be used to measure data noise, data
correctness, and reliability. Since a biomedical signal has a
weak signal and high noise, its analysis is very difficult, and
the application of the wavelet analysis theory to biomedical
techniques remains as an issue to be addressed.
A high-frequency sound occurs when the blood stream
flow meets with a resistance, and thus, is a non-stationary
signal. Such a high-frequency sound may be a feature
signaling the occurrence of a vascular stenosis. With its
good time-frequency analysis characteristics, wavelet
analysis has excellent performance in lowering noise and
singular point detection. To effectively find the singular
point in a signal, this study employs the wavelet algorithm
to analyze pulse wave data, using the wavelet
time/frequency domain analysis concept to resolve
time-dependent changes in a signal spectrum, in order to
analyze singular points in a signal. Wavelet transform can
be used to conduct simultaneous signal analysis in both time
and frequency domains, thus, overcoming the disadvantage
of the Fourier Transform in singular point processing.
According to the differences between singular point and
wavelet coefficients, when a singular signal is detected, the
detected data are further compared with an ultrasonic
detection graph; if accurate, then they are consistent,
otherwise, they are inconsistent.
2. Wavelet transform
A wavelet ( ) (t ) is a small interval wave [5], with a
limited length and a rapidly-attenuating waveform, with a
zero mean. There are various wavelet function spaces. This
study adopts the one square-integrable real function space
) (
2
R L , or:
) ( ) (
2
R L t = (Equ. 4)

A wavelet differs from the Fourier Transform in the
relationship of bandwidth e A versus central frequencye ,
where bandwidth e A is not related with the central
frequencye of the Fourier Transform, but is in proportion
to the wavelet transform, as expressed by Equ.(5),
C
e
e
A
= (Equ. 5)
where C is a constant, e A is the bandwidth, and e is
the central frequency.
When wavelet analysis is adopted, then the wavelet
generating function ) (t is a square-integrable real
function space, and the substituted transform must satisfy
the following equation:
2
( )
R
C d
e
e

e
= <
}
(Equ. 6)
Translate and dilate the wavelet generating function
) (t in order to obtain function ) (
,
t
a t
; where a is
International Journal of Advanced Computer Science, Vol. 1, No. 1, Pp. 16-22, Jul. 2011.
International Journal Publishers Group (IJPG)

18
distance, t is time; and t is displacement. The
representation is:
) (
1
) (
,
a
t
a
t
a
t

t

= (Equ. 7)
A continuous wavelet transform is defined as the
convolution of an unanalyzed signal ) (t x of the wavelet
generating function ) (t , at time t, and various distance
a [6], as shown below:
dt
a
t
t f a a WR
R
f
}

=

) ( * ) ( | | ) , (
2
1
t
t (Equ. 8)
) , ( t a WR
f
is the wavelet transform coefficient; if
rewriting time t to e , then a frequency domain
representation can be obtained [14].
The first step of wavelet analysis is to decompose the
original signal, and then extract the high-frequency and
low-frequency coefficients, as if entering highpass and
lowpass filters, as shown in Fig 1 (a). If a three-level
analysis is to be conducted, then a second decomposition of
the low-frequency coefficient must be performed, which
process is to first extract the high-frequency and
low-frequency coefficients, and then, run the third
decomposition of the low-frequency coefficient in order to
extract high-frequency coefficients, H1, H2, and H3, as well
as the low-frequency coefficient L3, as shown in Fig 1 (b).
Fig 1 (c) shows a representation reconstruction, where HF
and LF coefficients are obtained in decomposition, and H1,
H2, H3, and L3 must be reconstructed to a resolvable signal.
Upon completion of the above steps, the discrete wavelet is
inversely transformed as a reversing decomposition. The
reconstruction analysis signal is obtained as shown in Fig 1
(d), the reconstruction equation is as follows:


= ) ( ) (
, ,
t C C t f
a a t t
(Equ. 9)
This study adopts a bandpass filter to locate a signal within
a frequency range of 500 Hz~1,000 Hz, and conducts
wavelet three-level decomposition. Level 1 is reconstruction
in 1,000 Hz~750 Hz and 750 Hz~500 Hz, Level 2 is
reconstruction in 1,000 Hz~750 Hz, 750 Hz~625 Hz, and
625 Hz~500 Hz, and finally, Level 3 reconstruction is
performed in 1,000 Hz~750 Hz, 750 Hz~625 Hz, 625
Hz~575.5 Hz, and 575.5 Hz~500 Hz (Fig 2).
Fig. 1. Wavelet decomposition & reconstruction diagrams: (a)
Flow chart of wavelet decomposition at Level 1; (b) Three-level
wavelet decomposition diagram; (c) Three-level wavelet
reconstruction diagram; (d) Flow chart of wavelet reconstruction at
Level 1.

Fig. 2 Three-level wavelet reconstruction graph.

Low
coefficient
L3
High
coefficient
H3
High
coefficient
H2
High
coefficient
H1
Low
coefficient
L3
High
coefficient
H3
High
coefficient
H2
High
coefficient
H1

(a)
(b)
(c)
(d)
Wang et al.: The Detection of Arteriovenous Fistula Stenosis for Hemodialysis Based on Wavelet Transform
International Journal Publishers Group (IJPG)

19
3. Experimental
Clinically, vascular stasis easily occurs at four points,
namely, the fistula-vessel junction or puncture site, puncture
site arterial end (blood is pumped to dialysis machine),
puncture site venous end (blood is sent from dialysis
machine back to blood vessel), and artery/vein fistula
junctions. As patients arteriovenous fistulae are hidden
under the derma, the signal is weak. Most transplanted
fistulae are under the skin, where signal collection is clearer,
thus, measurements are mainly performed on an artificial
transplanted fistula. An artificial fistula (artificial vessel) is
created in two ways, a linear type (Fig 3 (a)), and a U type
(Fig 3 (b)). Clinically, ultrasonic detection of stenosis has
two criteria: 1) when the blood flow ratio at the arterial end
is over 3 (Fig 3), and over 2 at the venous end (Fig 3), then
there is vascular stenosis; and 2) when the measurement
point flow rate is above 400cm/sec, valid even if the flow
ratio does not reach criterion 1, it is still determined as a
vascular stenosis. An inherent characteristic of a continuous
vascular stenosis is that a majority of the vessels have
become smaller, thus, the bloodstream continuously passes,
which results in a faster blood flow. This study determines
stenosis from ultrasonic blood flow data, compares
measurement computation results with ultrasonic detection
results (Fig 4), and then, utilizes their relation to validate the
algorithm of this study.
Fig. 3 Ultrasonic test points schematic: (a) U-type transplanted
fistula; (b) linear transplanted fistula.

Fig. 4 Ultrasonic measurement and collection data schematic (The
highlighted number at the bottom left is the measured blood flow
rate).

In ultrasonic measurement, vascular shape, position
and pulse are clearly visible to identify and measure the
vessels. This study has two test points, and one is
arteriovenous fistula surgical mark (Fig 5). In Fig 5 (a), only
one surgical mark serves for the convenience of surgery and
patient skin recovery. The internal arterial fistula and
venous fistula junctions are very close, and one surgical
mark is visible at the surface, thus only one point is to be
measured. The other point is the junction of an arterial end
and a venous end at the puncture site, which normally has
an eschared mark on the surface (Fig 5).

Fig. 5 Stethoscope test point schematic: (a) U-type transplanted
fistula; (b) linear transplanted fistula.

A ten-second signal is sampled, and the maximum value is
extracted for every second. Every 10 signals are sequenced
in order to choose the maximum median, which is
synthesized into an analysis signal. This study uses two
methods to determine data availability: 1) frequency domain
analysis 3D and 2D graphs, and 2) time domain wavelet
three-level reconstruction. Frequencies are shrunk into one
block, time-frequency analysis is conducted, redundant
noise is checked (voltage noise, artificial noise) and
compared against the time domain and frequency domain
analysis results. Wavelet transform is performed on
consistent signals, then, the three-level signal is analyzed,
and the first level signal is converted to a power spectrum
by Hilbert transform [7]. The threshold is obtained to
increase visibility, and if there is a significant feature, it is
stenosis, otherwise, there is no stenosis (Fig 6).

Fig. 6 Algorithm flow chart.
(a) (b)
(a) (b)

International Journal of Advanced Computer Science, Vol. 1, No. 1, Pp. 16-22, Jul. 2011.
International Journal Publishers Group (IJPG)

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Fig. 7 Hardware schematic.

In data collection recording begins when a patient
receives ultrasonic detection, and a condenser microphone
is placed into the stethoscopes chestpiece. The signal is
amplified through an audio amplifying circuit, and passes
through the designed analog bandpass filter [8]. The
required bandwidth is captured and saved to a computer for
further analysis (Fig 7).
The recorded signal is an audio signal, where the
normal audible sound ranges between 50~20 kHz. The
statistic analysis finds that, the blood flow signal consists of
a fundamental frequency signal and carrier wave, which
bandwidth depends on the extent of the vascular stasis [9].
Through examining the information of the
bandwidth-dependent carrier wave, vascular stenosis, and
its degree, can be determined [10].
4. Experimental Results
In singular point detection, when a signal is interrupted
or discontinued, the signal has singularity. When a signal
changes, the slight change will be within a certain range,
which differs from noise. Singular point detection
recognizes singular points among the signals, and is defined
as the basis of the stenosis, and is analyzed.
After sampling the 10s signals from the original signal,
this study employs a time-frequency comparison in order to
enhance data accuracy. When using Matlab software and
plotting in 2D time domain, the problem cannot be shown
accurately; however, if transformed into a frequency domain
for recognition, the difference can be directly found. The 3D
graph, as below, is plotted after transforming into a time
domain; where the light color is intense, and the dark color
is tranquil, as too light a color affects judgments, and a 2D
graph is added for comparison. Fig 8 shows a stenosis-free
case, and Fig 9 shows a stenosis case.

Fig. 8 Stenosis-free representation: (a) 3D representation; (b) 2D
representation.
Fig. 9 Stenosis representation: (a) 3D representation; (b) 2D
representation.
A bloodstream signal consists of a fundamental
frequency signal and carrier wave, which bandwidth
depends on the vascular stasis. As shown in Figs 8 and 9, as
there is no embolism, the stenosis-free case manifests as a
regular blood flow signal (Fig 8), while the stenosis case is
affected by a carrier wave, which bandwidth depends on
vascular stasis (Fig 9).

Fig. 10 Wavelet three-level reconstruction representation: (a)
Stenosis-free representation; (b) Stenosis representation.
Fig 10 (a) shows a regular stenosis-free waveform in
wavelet analysis. In Fig 10 (b), the stenosis wave is mixed
with a carrier wave, which bandwidth depends on the
vascular stasis, and results in an irregular waveform.
Figs 11 and 12 present the power spectra, after Hilbert
transformation of a Level 1 signal, which is reconstructed
after wavelet decomposition. Obvious features occur at
700~800 Hz. Fig 11 shows a stenosis-free case, and Fig 12
shows a stenosis case. Whether the blood vessel is narrowed
can be seen from the threshold judgment. In this study, if
the signal is above the threshold, then the threshold is
subtracted in order to facilitate identification, this detection
threshold is shown as follows:

f
W threshold max 15 1 = (Equ. 8)

(a)
(b)
(a) (b)
(a) (b)
Wang et al.: The Detection of Arteriovenous Fistula Stenosis for Hemodialysis Based on Wavelet Transform
International Journal Publishers Group (IJPG)

21

Fig. 11 Stenosis-free Hilbert transform: (a) power spectrum; (b)
threshold judgment.
In Fig 11(a) there is neither a significant feature, nor a
singularity. In Fig 12(a), the significant feature is in
700~800 Hz, which is the stenosis criterion in this study.
Thus, Fig 12(a) is supposed as having stenosis. Fig 11(b)
and Fig 12(b) show a greater visible threshold judgment
result than do Figs 11(a) and 12(a).
In this study, if the signal is above the threshold, then
the threshold is subtracted. Fig 11(b) is obtained after a
threshold judgment, as the signal does not exceed the
threshold and 0~100 kHz interval is due to a fundamental
frequency effect; and therefore, it will be neglected. In Fig
12(b), there is significant rise in 700~800 Hz, which
suggests that a stenosis has occurred. It can be assumed that
the carrier wave at the stenosis falls within 700~800Hz.
This study has 83 groups of valid data, and after
comparing the Hilbert transformed power spectrum with the
ultrasonic detection results, 71 groups of data are correct
(consistent with ultrasonic detection results), accounting for
85.54% of the total data; and 12 groups of data are
misjudged (inconsistent with ultrasonic detection results),
accounting for 14.45% of the total data (Table 1).

Fig. 12 Hilbert transform in case of stenosis: (a) power spectrum;
(b) threshold judgment.
5. Conclusions
This study developed an algorithm to determine if
hemodialysis patients have arteriovenous fistula stenosis.
According to the statistics of all patient data, vascular
stenosis affects the high-frequency component in a
bloodstream signal. It is preliminarily judged that
singularity occurs in 700~800 Hz; and when transformed
into a frequency domain, it is also clearly recognizable.
High-frequency sound occurs when the bloodstream is
subjected to resistance. Such a non-stationary signal is a
probability feature of vascular stenosis. This study
employed a wavelet algorithm to analyze pulse wave data,
and used the wavelet frequency domain analysis concept to
(a)
(b)
(a)
(b)
Table 1 Simulation results
Sequence
Comparison with
ultrasonic detection
results
Number
of data
groups
Percentage of
total data
A Not consistent 12 14.45%
B Consistent 71 85.54%
International Journal of Advanced Computer Science, Vol. 1, No. 1, Pp. 16-22, Jul. 2011.
International Journal Publishers Group (IJPG)

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resolve time-dependent signal spectral changes in order to
analyze singular points in a signal. A singular signal can be
detected from the difference between an abrupt singular
point signal and wavelet coefficients. If a signal is broken or
discontinued, then this signal is singular at that point. When
a signal changes, it would be slightly over a certain range,
and thus, would be different from noise. Hence, singular
point detection is to recognize a singular point within a
signal, and is defined as stenosis criterion before analysis.
Moreover, detected data are compared with ultrasonic
detection results; if accurate, then they are consistent,
otherwise, they are inconsistent.
After processing the signal and wavelet transform, there
is a stenosis feature in 700 Hz~800 Hz, indicating that
vascular stenosis affects the high-frequency component in a
bloodstream signal. Threshold judgment and statistical
analysis are conducted on the data of all patients. The
success rate is 85.54%, and the misjudgment rate is 14.46%.
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Yen-Nien Wang was born in Taipei,
Taiwan in 1968. He received his B. S.
degree from the Dept. of Automatic
Control Engineering, Feng Chia
University in 1991, M. S. degree from
the Dept. of Electrical Engineering,
National Taiwan Institute of Technology
in 1993 and Ph.D. degree from the Dept. of Electrical
Engineering, National Taiwan University of Science and
Technology in 2000. He is currently an assistant professor of
Electronic Engineering at the LungHwa University of
Science and Technology. His research interests include the
digital signal processing, digital communication, artificial
intelligence, and bioengineering.
Chih-Yang Chan was born in Taipei,
Taiwan in 1965. He received his M.D.
degree from the Dept. of Medicine,
China Medical College in 1994 and
Ph.D. degree from the Graduate Institute
of Physiology, National Taiwan
University in 2007. He is currently an
Attending Surgeon of the Department of
Surgery, National Taiwan University Hospital and an
Associate Professor of the Medical School, National Taiwan
University. His research interests include the Vascular
Pathophysiology and bioengineering.

Shi-Jun Chou was born in Taipei,
Taiwan in 1985. He received his B.S.
and M.S. degree from the Dept. of
Electronic Engineering, LungHwa
University of Science and Technology
in 2008 and 2011, He is currently an
assistant professor of Electronic
Engineering at the LungHwa University of Science and
Technology. His research interests include the digital signal
processing and artificial intelligence.