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Haemodialysis Access Shunt Evaluation

Sep 07 | 1:30 PM

Join Dr. Pankaj Sharma as he discusses several fascinating concepts in hemodialysis access shunts, as well as their evaluation and best practises. Join us for this insightful event by KREST, Kochi organized in association with IRIA, Kochi.

[Music] good evening everyone today we are starting a new series by crest kochi which is very popular amongst radiology residents and consultants last year they organized more than 250 talks through one 130 free webinars this series we are starting another chapter in crest kochi i request all to join the crest club in this platform to get regular updates on crest kochi scientific sessions we have professor mr balachandran head of department radiology from jubilee medical college trishur to welcome the gathering over to you sir thank you judy for uh and today the crust is going to introduce one of the best teachers of iria and also budding leaders of ira fi cri pdc's in gastro radiology he had done a fellowship in abdominal radiology fellowship in vascular and interventional radiology now he is working as associate professor at the department of radio diagnosis and managing all india institute of medical science rishikesh so he has been in various teaching forums and he has conducted many workshops today we'll be listening from him about the hemodialysis axis shunt evaluation dr uh pangasima uh he's he has been to kerala many times he has been felicitated by ira at chandigarh for his various activities especially in uh in the country especially when he has done a lot of work in increasing the membership of ira and all the other activities also it has been bestowed with the distinguished doctor award by the so i welcome dr pangas for this session this uh topic is very special because most of the radiologists have no much access to this investigation but this hemodialysis accession is easy to evaluate and because the graft is so superficial and if we can identify and localize normally abnormalities potential threat to the uh access can be prevented so and so i with this i welcome dr pankaj i welcome dr uh [Music] all the delegates i welcome keshavdas dr amish and i and now i request judy to take her and hand over the session sir we have an equally prominent personality to give the opening remarks on the new venture by crest kochi he is well known all over india and that is professor dr c keshevadas associate dean of sritra tirunal institute for medical sciences tiruvanthapuram welcome sir over to yourself thank you dr judy thank you valentin sir first of all let me welcome my friend pankaj sharma pankaj is in the prestigious orange institute of medical sciences rishikesh and i have been i have known him for quite a long time he is a leader for excellence and has been actively involved in the activities of radiology both teaching as well as administrative now regarding the topic what christ has chosen is a very important topic because it it is a collaborative work hemodialysis creation is a collaborative work where vascular surgeons radiologists both interventional radiologists and diagnostic radiologists and also the nephrologists all work together and we are the hemodialysis as you know is important in patients with end-stage renal disease and to see the patency and to see the functioning it is always important that radiologists plays an important role so we have to have frequent communication with the vascular surgery department as well as the depart the nephrology department several techniques are being used and i am very sure pankaj will be illustrating these techniques of course doppler ultrasound still is the technique many people follow if you have problems you might have to go for techniques like ct but it's only a problem solving tool and interventional radiology whenever it is being planned for the suns then you might have to do a dsa so radiologist plays a very central role and i am sure that in institutions where there is a very active nephrology department radiology department and the department of vascular surgery we can together start doing a lot of good work for saving these patients so with these introductory remarks i welcome pankaj for this i am actually hearing this topic for the first time because this is not a topic which is very commonly discussed in the many radiology meetings and i am extremely happy that christ has taken such an important topic for discussion thank you and welcome uh pankaj for the talk thanks a lot sir first of all i would like to thank dr balachandra nayasar and dr keshav for such an uh nice introduction sir i am obliged thank you second i would like to compliment chris kochi thank you they have been doing uh such a beautiful and uh informative academic uh webinars and uh so many members in this covered time have been able to gain knowledge through this webinar so thanks uh chris kochi and the entire organizing team for hosting this webinars so now i will start just a minute yeah now so uh i'm i'm talking about a very important topic that is hemodialysis assession evaluation see every radiologist has ultrasound and doppler with him or her and importance of this technique is that we can easily assess these shunts uh hemodilation and important thing which all radiology should be 600 ml per minute that means 10 ml per second and if the this if there is any problem then this high flow rate is not there so and doppler is a armamentarium which each intervention radiologist uses for assessing these sessions uh and if there is any problem then their decisions are taken based on how we evaluate this chart so when we are when we have to talk about this uh these uh which uh uh artemis fishlers are the most common preferred by all all nephrologists and this can be brachiocephalic fishless brachiobacilli uh radio safely facilla so native artemis fishler is the vascular essence of choice for hematitis patient and artificial switchers are always preferred over artery venous graft and central venous catheters because arterial venous fissiles last longer and have fewer complications and duplex ultrasound is punishes uh both morphological and functional data on the native vascular access so a doppler duplex ultrasound is used for pre-operative vascular mapping for identifying the vessels that are suitable for fish law creation and after uh fish grass created if there is if these fishes don't mature or after after these have matured but are due to repeated usage there isn't any problem then duplex ultrasound is used for post-operative surveillance for early detection of complications by duplex ultrasound but before any radiologists uh start doing ultrasound or doppler important is there uh to know that we assess these specialized to assess uh this fish loss if we are feeling thrilled properly then nothing more needs to do it is only when the the you don't feel thrilled properly you have to do other things then uh important point we should know is if you are talking about fish law or graft there are two ends what happens is the vein is connected to the side of the artery and this is the junction and from there the blood flows from artery to the vein so what happens is slowly and slowly these veins get arterialized and and uh due to this actualization uh they will have so slowly and slowly the changes in the vessel wall in the vein wall and there are two puncture side first puncture side is just near near the anastomosis and here the needle is directed toward the junction the anaesthetist and this is the arterial leader puncture side and second is high up on the v inside uh the puncture side towards the central wave so blood will move from the artery through the anastomosis into the vein and through this artillery puncture needle to the hemodialytics machine and from their hemodialysis machine the blood will come back to the venous end of the puncture side and move from the vein to the central veins and and uh the these swissla these can can be artificial or they may be graft artifice graph like shown in this image on the left side you have facili and on the right side you have a loop graph which is a synthetic graph which which has communicated the artery to the vein then this this technique was first described in 1966 by bresca and colleagues and uh we had famous brescia camino a artemis switzerland and they the what the their describe was radio phallic artemis switzerland where an autologous fishing was constructed between the radial artery and the cephalic queen at the wrist so the these are the adjectives due to which we had a first introduction of arterial switch lab and they introduced radiophilic facial they can be of different types the rescue criminal artificial was in sight of artery to end of the weight as shown in the second image from above the blood was coming coming through the artery uh it was side of artery and end of the vein and this is the most uh preferred uh type of facility by all nephrologists then other type of uh arduino can be side of artery to side of it which is which is not much preferred then it can be end of artery to side of wind or end of rt to end of it so more than 90 percent of times it will be side of artery to end of it which is preferred by the nephrologist then the these fish can be at different sites like shown in image this this is a side of the radial artery and the cephalogram the this is a radio kefiri fistula which is described by uh vascular chemist second uh image is showing the brachial artery communicating with us is a medium median capital branch of civilian so so this is a brachiocephali fish line third image i see is showing the vehicle artery communicating with the basal liquid then uh coming to graph graph can be of different uh types it it can be straight graph like in image where the graph is between brachial artery and the basilic ring and f there is a loop graph between actually artery and actually in d it's a it's between uh brachial artery and basal and cephalic and uh g is the femoral graft the femoral is the least referred because of high high purpose perspiration and there are high chances of infection then what are the technical requirements and examination technique for assessing the spatial and graph first we should have a linear probe with minimum frequency of seven megahertz for the b mode examination and five megahertz for the doppler study the then preferred is supine position with the trunk moderately elevated to avoid flexion of the elbow so we have to uh eat the elbow straight and we have to avoid flexing the elbow if alternately patient can be seated in front of the operator with the forearm resting on a stand so so important is that that we keep either spine with the uh straight elbow no flexion or we make the patient sit in front of the operator with a forearm resting on a stand and uh supine position is preferred by most examiners then important is that examination should be carried out in a comfortably warm room and gel should be warmed uh to avoid triggering vasoconstriction of the structures being examined when you start examining we start first from the arterial side arteries are evaluated from the root of arm toward the hand until the point of anaesmosis then we evaluate the anastomosis and then we evaluate the ways beans are related from the peripheral towards the thorax and whenever we are evaluating artery or vein we have to do both transfers and longitudinal scans of the rtn base we have to see in both then coming to util examination what are the important uh things we will look for when we are doing the pre-operative evaluation of the arteries first is we will assess the diameter second we will assess the arterial wall morphology third will be evaluating the reactive hyperimicrismos and fourth we will be evaluating the patent department arch or modified duplex ln test then coming to rtl diameter m mode is useful in small caliber artists some systolic diastolic uh diameter variation can be seen due to velocity so if if if it's uh arteries uh diameter is less than 0.5 then in some cases we can uh use m1 but the preferred is b mode here what we do is in beam mode we place the artery in the longitudinal plane and longitudinal plane is preferred over the transfer our transverse planes for missing the diameter when we have to measure the diameter we always measure the diameter from intima to intima like in in the in on the left hand image a to a cursor is is the diameter of the artery and b is the b2b is the intima media thickness of the artery so uh from intimate to intima we have to measure the diameter and intima medial the thickness is measured separately then coming to saw artillery morphology what we have to see we have to see for the smoothness of the internal media thickness measured using high resolution ultrasound as i have already told from in this image from b to b and third we have to see if they is there any calcification or not is there and whether this calculation is signified or not then when we start we start how we have to report see see this is the format how we have to report we have to measure both the diameter and the depth of the artery from the skin because for fishleg creation we want artery and vein to be superficial not deep so what we will do is we will draw a diagram like this and we will write like here in this case when we're talking about brachial artery the diameter is 0.46 and the depth is 1.3 centimeter so in simple uh drawing we you can write and you can communicate to the surgeon that these are the diameter and this is the depth now similarly for radial artery it is 0.244 is the is the diameter and 0.5 centimeter is the depth of the artery for our similarly we will measure and we will we will communicate to the surgeon then talking about how how much uh what the literature is and what evidence is there the malware at all reported immediate and early failure rates of 55 and 64 respectively when the artery had used at a diameter of less than 1.5 mm whereas much lower rate eight and 17 percent was observed when the rtl diameter was more than five one point five so the artery uh chosen is the generally artery which has diameter more than 1.5 mm second it should not be at too much depth voice should be smooth intima media thickness should not be more than point one and prefer this there should not be any calcification when we have to measure intimate medial thickness then it's estimated in the longitudinal scan of the distal wall of the artery and increased thickness closely correlates with the fistula failure so surgeon always wants a pristine r3 which is not very deep that diameter is more than 1.5 mm and and the interim media thickness is not much and preferably it should not have calcification then when we normally what happens in artillery artery uh the waveform is uh triphasic waveform so so we we see for these arteries the depth and everything and we do the doppler spectral evaluation when a fistula is created what happens is the radial artery just just proximal to the fistula which demonstrates spectral broadening and diastolic flow characteristically in rtl beds with low rest and outlook so what happens is because the blood flow is going from artery to anesthosis into the vein so there is low resistance along with low resistance there instead of triphasic waveform we will have a high elevation in peak systolic velocity and in end diastolic velocity so we don't have any triphasic waveform then we will have uh monophasic waveform with high pitches lowerly velocity and high end diastolic velocity which is not reaching near the baseline second thing what will happen is there will be spectral bonding see uh if if if you are talking about waveform which is normally seen in artery it will be like somewhat like this triphasic waveform and uh in try phases that uh it will be touching the baseline and going below below the baseline whereas once a facility is created what happens is there is low resistance there is spectral broadening mixed solid velocity increases as well as end diastolic velocity the never touches the baseline so this is a this is important and in in the absence of dialysis access a normal radiative will always exhibit triphasic waveform with no spectral broadening and psv more than 40 centimeter per second if you see the uh this uh rtla evaluation before the anasmosis the artery is showing flow rate as high as more than 2 meter per second that means more than 200 centimeter per second the peak systolic velocity has uh more than 200 centimeter per second and see the end diastolic velocity it it is more than 150 centimeter per second and you are seeing spectral broadening which we don't normally see in arteries then the uh this is showing the spectral image of the normal uh inflow artery of the artery this uh graft of fish lab which shows a normal moon offense is low risk waveform with moderate turbulence so this is important to evaluate when you are where you are doing during the evaluation of facial facilitation and this is normal waveform order to the site of anastomosis and here according to essence we will find high resistance tri-based uh triphasic waveform so before the the arterial waveform waveform will be will be a low resistance waveform with lot with moderate turbulence high pixel strolling velocity and high and diastole university whereas how the waveform will be in the vein the spectral uh doppler image of the outflow being in a arduous graph or within a artifice will be monophasic and turbulent artillery type waveform because this vein has been artillized so turbulence on the monophasic waveform spectral bordering high pixel strolling velocity and end diastolic velocity which is high which never touches the baseline is the normal expected uh expectation then uh in this case we we are seeing the similarly monophasic flow with large diastolic component with low resistance and uh see the flow rate flow rate here every equipment now this is as a software and we have to properly measure the diameter from intima to intima and then we get the flow rate in this case it is as high as 2776 milliliter per minute and normally what we require is flow rate more than 600 per milliliter per minute and we have to understand that these patients have to go under catalyst at least twice or twice in a week so these these are a high flow rate fish class and they have to be made functional then successful radius uh functional studies should always involve assessment of blood flow and the arteries uh ability to dilate and successful radius valley fish like uh construction is is associated with radial artery flow rate exceeding 50 milliliter per minute and this uh and pre-operative radio flow rate of less than 20 milliliter per minute is associated with an increased risk of primary av facial failure special failure within eight months so this flow rate has to be a high uh and when we are choosing the uh the surgeons chooses the artery for construction they look at it at all these points and we have to convey to them this is a the image which shows up how the flow rate is calculated depending on the mean velocity the area and uh and multiplied by 60 seconds and we have to accurately measure this diameter from intima to intima any uh if you don't measure it properly then flow rate uh we get is not actual for what we want then uh uh coming to the first vessel diameters measured on the appropriate and large b mode image and the first doppler is then activated and prf is adjusted to eliminate artifact this is important then the mean flow velocity is calculated from the time velocity curve using the time average you lost option available in most scanners and most ultrasound modern ultrasound scanners are equipped with the computing algorithm for automatic calculation of the fischler flow rate so what are the tip flow of volume flow measurement first is avoid significant turbulence we should have circular flow of accurate diameter dimension of vessel diameter which i've already told adequate insulation angle and insulation angle should be less than 60 degree sample volume should cover the entire area of sn there should not be significant diversion of blood flow through access remains so we should select the area properly and uh we should uh by diagrammatically the description we we should tell which are the areas where the the diver there is diversion of blood flow to assessment so that the intervention radiologist can tackle those accessory veins and flow is determined in feeding artery if complex mean and if there is a complex vein and various algorithm are used by manufacturers by up to 30 and slight error in one parameter leads to earnest numbers so we should be very careful to minimize the risk of underestimate caused by hemodynamic factors like hypertension dupless ultrasound should not be used to calculate if it's volumes during the immediate post dialysis period so you should avoid evaluating immediately after dialysis has been done for the patient and measurements made between one session and the next are immediate before the dialysis session are preferable a welfare extreme av facility is characterized by flow rates are varying from 700 to 1300 milliliter per minute and less than 500 ml per minute is protected of asses dysfunction and less than 300 ml per minute is predicted of immediate thrombosis so on the basis of data collected uh by lamented co-workers it appear it appears that maturation is likely if the blood flow through the fish lie is uh 250 to 500 milliliter milliliters per minute in the post-operative day one and 500 to 900 milliliter per minute one month after construction of the ionosmosis so immediately if you are assessing immediately after the fish lies we created on the day then flow rate between more than 250 is a british of success and one month then it should be more than 500 milliliters per minute so interpretation of fistula flow volume normal flow as i have told that mature fish lab will have flow rate more than 500 milliliters per minute and normal value in forum fish life is somewhere between 600 to 800 ml per minute and upper arm facilities can be weighing from 900 to 1200 mil liter per minute when we talk about risk of occlusion then a av facility flow rate less than 300 meter per minute has a high chance of occlusion and if we talk about graph then flow rate less than 650 milliliter per minute as chance of occlusion and we want high flow but too much high flow will also cause problems so if an adult the flow rate is more than the 3000 milliliter per minute then the patient can land in high output cardio failure and in children flow rate is more than 5 700 ml per minute it will can be a little high output cardiac failure then how to how to do reactive high premium response what we do is the patient is asked to clench the fist to toe for two to three minutes what happens when the patient does uh clench your fist test there will be a high resistance triphasic flow then patient is after two to three minutes is asked to release the face and when the patient releases surface this high resistance will be replaced by low resistance monophasic flow so these physiological increment in blood flow through an artery that occurs after after a period of stimula is what we what we want to assess by doing reactive high premia response and failure of such response is predictive of immediate force operative visceral failure so is it easy to do test only takes two to three minutes patiently it has to clench fist you see the high resistance to uh basically flow and then we are the patient to release and do you say monophasic flow of waveform if there [Music] uh there will be a higher chances of immediate post-operative even fishleft failure then ishmael's inducer as i've already told how to address them and uh greater the intensity of reactive happiness lower the ri will be so this is showing uh blank fist and after uh and when the there was tensions there is triphasic before and when the uh fist is released there is a monophasic wave flow of form with low low resistance then second test we can do is modify duplex allen test patency potency of the deep raj what we do is duplicate ultrasound of the of the first first digit is done with manual compression of the radial artery showing reversal of flow indicating adequate collateral circulation to the hand so we press that a radial rt and we see see for the reversal of the flow indicating adequate collateral or to the hand so then then we assess the flow volume flow in the fish line is uh assessed by flow volume in proximal a and flow volume in distance so we assess our volume proximal to the fish layer and flow volume distal to the fish la and the difference is the flow through the fish lab and what happens during steel syndrome is that the flow which uh the blood flow which we normally were expecting to go from artery to anesthosis into the vein it will not go into the artery and there is a steel phenomena there is reversal of flu from other side so this reactive hyperemia is a test which is helpful in evaluating during steel syndrome and what what surgeon or interventional radiologist does in stereo syndrome is they they try to create a high resistance in the fistula so that blood goes not a preferential blood does not go through the fish line into the vein but goes for a straight from the artery instead of maximum blood going into the fish lab maximum blood should be diverted to the distilled uh to the anastomosis into the artery in still water actually is happening is blood is going through the facility and the the distal uh part of the hand wrist the the there is steel and the from what happens in this opposite side the artery the blood flow tries to compensate so we can very well evaluate uh in these cases the sealed syndrome by duplex ultrasound and intervention radiologist or surgeon can tackle this situation if we report it properly then uh this uh this is showing spectral image of the left way trail rt digital to av fish shows trace arterial flow flow and after compression of the fissile flow in the radial artery improves substantially with increased psv and waveform will breaks arterial after the symptoms also include after compression so uh if they if we are evolving steel syndrome the then we can press the fistula and see that the blood flow increases a distal intra artery if it is increasing then we can easily communicate to the intervention radiologist or to the surgeon that you have to tackle this fisla and if you are decrease the blood flow to the fistula the blood flow will increase distal in the artery and steals our syndrome can be tackled this is how we will see the blood flow in the fish la where there will be very turbulent flow over long stretch and there can be sometimes perivascular vibration then uh the the this is a image is showing normal arterial special are demonstrating mass spectral bonding and elevated velocity which i have already told and spelling queen in this image is a relatively superficial sitting just about a centimeter or less below the surface of the skin as denoted by skin to right of the color flow so when we start the venous examination we have to similarly assess for diameter and depth from the skin surface we have to assess for compressibility we have to uh essence for lumen potency and echogenicity we have to assess for wall irregularity we have to assess for presence of accessory veins or collateral and we have to assess for respiratory facility if because here this if there is any central stenosis then this respiratory facility will be lost so coming to first to the diameter and depth from the skin surface what we do do is we measure from in a part of the vein to in a part as a as shown in the image and if a sclerotic or thick vein is seen the inner aluminum diameter should be measured and depth of the cephalic or basilic vein should be measured from the skin surface to assess the need for a subsequent supervisation positive this is important because the the these uh these puncture both arterial and venous side in the vein only the arterial end is just near the anastomosis in the vein and the the wheels are the the weak side is just a few centimeters higher in the vein so we are actually not not punching puncture in the artery but we we are we are puncturing the vein at two points and this way should be superficial for easy assay so the so that this can puncture can be done easily then uh we have to evaluate for venous venus as a distance ability you are doing preoperative mapping and diameter vessel is measured before and at least two minutes after placement of a tonic this is important you have to assess both without tonic and two minutes after the placement of tonic and tonic head should be tight uh with pressure high enough so that the vein diameter is occluded but the arterial flow is not stopped so uh we can also use uh sphygmomanometer cuff to inflate it operation of 50 to 60 millimeter mercury uh and and uh we evaluate the percentage of increase after a uh cuff is inflated lockhart reported that cephalic base with a pre-tonic diameter of more than 2.5 mn and smaller veins with that post-onicate diameter of 2.5 mm were equally useful for creating dialysis so when we are assessing uh fish vein we have to look for into that these means are superficial second we have to look for that the diameter is at least 2.5 mm uh before before uh if it's a large win and if it's a small mean then post tonight diameter should be more than 2.5 mm otherwise there are hard chances of failure and this is how we have we have to write the report like artery we measure we have to write both diameter and depth on the surface similarly here we can we can put both the things the diameter and as well as the depth from the skin surface what happens if there is an image or fish la or or if there is a small and deep vein like here the vein is too small the diameter is 3.5 mm and vein is too deep more than 6 mm in the diameter or the vein is 67.67 ah deep so the surgeons always prefer a large diameter weight and a wheel which is uh as close to the skin surface as possible then we have to look for the compressibility like in this case uh the compressor the pro using probe the vein is compressed and you see the vein is compressed however the artery is seen non-compressed then what can what can happen sometimes is if this switch layers are not working properly there may be thrombosis can be seen like in this case we are seeing complete thrombosis in a vein and partial thrombosis in another way so you have to report which segment of the vein has partial thrombosis which is a complete composite because the magnitude depends on that here also there is a chronic compass in a av fish la and we we are seeing uh in a case of field av facilia and organized the compost filling almost the complete lumen of the vein and the you can see due to chronic the lumen of the fish is beginning to contract around the thrombus then assessment of outlook we have to assess the outblow means and these are veins as they are arterialized they have pastel flow and spectral borders this is a case where duplex ultrasound has been done in a recently created transpose basic facilitator transposed basic facility which is maturing well so when we see the sk scale uh to the right of the image it confirmed that a five centimeter length is superficial enough enough for easy cannulation lying only point uh 0.5 centimeter less from the skin surface and the diameter measures 0.73 centimeter and and when you see that the peak systolic velocity it is 189 centimeter per second and diastolic velocity is 123.9 centimeter per second and flow rate see the flow rate as i is 1792 milliliter per minute and diameter is 0.73 so so this is a what we expect when fish la is matured well and what when we will it from the venus side and this is a case uh uh where we are seeing uh cephalic with thrombosis in first image we are sensing normal flow and we have a pattern at the site of ns and osmosis and the second third bnc image we are seeing a combust in the cephalic bandwidth sluggish flow in the venus site and when when dsa was done where we are and this is been done by assassin from the venus side we are seeing complete occlusion of the cephalic wind with no passage of contrast to the artillery side then successful uh uh in e image we are seeing successful passage of wire through the combust and contrast crosses to arterial side through the constricted uh radically fissile and after repeated after at particular transformation angioplasty using balloon of increase in size the av has restored his patency and when we when we are seen seeing the duplex ultrasound in the h image we can see patented it with the image in the b then sometimes what can happen is there may be immature facility can be due to large accessory wing like in this case we are seeing a large accessory when which might limit the maturation on official and when we are evaluating uh duplex ultrasound we have to search for all accessory means with within first 10 centimeter of the atmosphere so this is very important if the if the fish lie is not maturing then assess the form of artery assist the anaesthetist and first enter 10 centimeter of the draining vein because here you can find a accessory collateral which needs to be tackled for uh making this fish lava then sometimes what can happen is uh this venus aneurysm can form because what happens is you understand that these first these native wheels they have been utilized due to high fluid the wall has thickened second is multiple punctures as i told two twice or thrice puncture in a week so this a and uh v side are function multiple times due to the repeated punctures due to uh flow dynamics changes due to increased thickness uh sometimes what can happen is uh anism and pseudonym and these venus energy are commonly seen with the facial ass and are thought to result from repetitive puncture and they may remain static for many years and usually do require no treatment if skin covering the aneurysm is intact this is important however if the online skin is ulcerated bypass and excision of the aneurysm is indicated to prevent massive hemorrhage and pseudo-enrichment graft are second to tear of the graft wall caused by a needle puncture with the resultant hematoma formation see in this case we are seeing anismal dilatation uh the inner patient with a 50 they are male with chronic linear failure with left vcf uh av facility on physical examination there was painful arms swelling with suspected abrasive dilatation and when the duplex ultrasound was done we could see the annual tiltation of civilian with an organized combust within and patient underwent reconstruction of a of a new facility sergey was referred to angioplasty owing to the presence of thin-walled anism with organized numbers then another case where we can see narrowing of the arterinas fisla adjacent to due to adjacent hematoma and this hematoma is causing compression and we have to see the difference in diameter between the color fill and the segment of av fisla in the top left so normal venous duplex uh doppler spectrum is characterized by continuous low velocity flow which becomes increasingly physics as the examination process towards central bank and any absence of physicity means there is some uh thing wrong in central way or there is a central obstruction and the absence of such flow confirms the presence of obstruction and suspicion of stino or thrombotic lesions causing a involuntary central vein should be confirmed with a lipographic like in this case the case with central means noises in a patient with bc for av fish see in the top most a image we are what we are seeing is a colored on color doppler there is aliasing and turbulent flow confirming stenosis and uh the on b image there on spectral doppler what we are seeing is stranotic segment is showing uh elevated ps we see the psv more uh reaching almost up to 500 centimeter per second and then angiograph was uh done which shows several synonyms at the philippine and suburban main junction corresponding to what what could be easily picked on the sonography and doctor so when we talk about the normal dopplex ultrasound in every slab uh in breakage our artery said there will be monophasic flow with the diastolic component and a spectral body sorry and on the venous side we will see artillery's wing what happens in the if if there is a mature facial facial or low see the radial artery the flow rate see the flow rate as low as 86 milliliter per minute there's some more spectral broadening but the flow rate is very less and when come to venous site similarly the flow rate is 130 ml per minute then another case of a signal synosis of avicilia and esoc at arduino's fish law we are seeing highly turbulent blood flow with low rate as is 438 centimeter per second and uh when when we uh calculate the psv ratio it is almost 3.4 and when we measure on the radial artery side the psv is 130 centimeters so before uh before the stenosis the flow rate is 130 centimeter per second at the site of minus moses the flow rate at the peak systolic velocity is 438 and uh before that peaks solid velocity is 130 so psv ratio is almost 3.4 what happens if there is occlusion see before the occlusion uh the the artery is showing high resistance and high resistance with triphasic waveform and ri is almost reaching up to one and when we come to the uploaded uh segment there is occlusion of fish with the combust within the training so this is how what we expect to see if there is occlusion of the the fistula another case where we are seeing thrombosed breaker kevin fisla and waveform demonstrates to and through waveform characteristic of a vessel with no output and here we can see low psv the absence of color flow throughout the excess and the presence of ecogenic material within the fish lab all other findings are compatible with the assessed side thrombosis however sometimes what can happen is there can be pseudo diagnosis of significant synosis like in this case the peak systolic velocity is as is 350 centimeter per second with flow volume 1.1 liter per minute so there is high in flow when we come to fisla the psv is 5 centimeter per second and when we come to wayne side the flow rate is 175 centimeter per second with flow volume as 1.8 liter bonds so there is high inflow high outflow and high flow through fistula so the the in this case if we are say test gnosis then it's a pseudo diagnosis of signaling facility and high psv in this case is due to high flow volume and large version compare this with the with the previously shown k case uh here where before the uh the fish la the in the artery the peak systolic velocity was only 130 centimeter per second whereas the site of anastomosis in the official the peak systolic velocity was 438 centimeters per second so psv ratio is an important parameter which we should take into account then uh this is how a graph will look normally av fish graph can uh we will show uh the graph material which appears as two parallel echogenic line and this is the normal fine form how the graph will look for it and uh this is the how we will assess the flow through our graph similarly we are seeing the flow flow rate high flow peak systolic velocity high industrial velocity as well as spectral bonding and uh if if there is composition in a graph this is what we will see like in a image we are seeing hybrid thrombus filling the arteminous graph in the b image we are seeing a color doppler near complete thrombosis and uh see image we are seeing when we do spectrotopular imaging we see high flow high resistance triphasic wave this is how a pseudonym will uh look like in a graph what uh what has happened in this case is in the posterior wall of the essence graph there is a pseudonym and we see the typical yin young pattern of blood flow typically in pseudonymism then uh the this separation who had harm swelling and uh in the case of av uh graft and color doppler over the area of swelling shows focal narrow necked out watching containing a yin young flow pattern and cancer corresponding angiogram shows multiple pseudonym along the atomized graph [Music] sometimes what can oppose is they are joining to the switch graph there may be intramuscular hematoma this patient had arm swelling and fishlock arteries graft and in a grayscale we are seeing large intramuscular hematoma adjacent to graft that is nearly isolated to the surrounding tissue and color w is helpful in delineating the um from the surrounding tissue see the cc see that doppler in nematoma we are not seeing any doppler uh pickup color pickup but on on the surrounding region we can see the top so we can probably assess which is the size as a site of hematoma then uh sometimes what can even happen is there can be a paragraph infection in abscess in a patient with av graft without swelling and fever seen in the image we are seeing fluid tracking along the av visceral graft a big autonomous grout with increased echogenesis of surrounding soft tissue indicating surrounding inflammation and in the color doppler we are seeing focal fluid collection along the same uh official aircraft which is suggested of a focal absence so duplex ultrasound calculation of av facility can be also be useful for assessing the effectiveness of a therapeutic intervention carried out to resolve a complication the absence of increase in flow of at least 20 percent after such indeed intervention indicates that the treatment has failed an alternate solution so we can assess this fish line graph before intervention we can diagnose then the interventionist can do the procedure and we can assess afterwards if there is increase if there is absence of increase of inflow of at least 20 percent then that means that treatment has failed and an attribute solution is needed and systemic assessment of av fish love with their adopters ultrasound is a challenging and time consuming procedure that should be done only by our experienced operators and we always have to follow the rule of 6. what it means is we identify that nuclear ultrasound characteristics that confirm that a fish line is mature and therefore ready use cost is flow volume more than 600 ml per minute second and outflow diameter of more than 6 mm and third is outflow wind depth of less than 6 mm below the skin it should be a superficial vein so the depth less than 6 mm outflow in diameter of more than 6 mm and flow volume of at least 600 ml so then what are the ultrasound factors for successful uh av fish recreation in fairfield artists the radial diameter at a risk should be more than 2 mm some authors use 1.66 mm criteria there should be reactive hyperemia response i have already told how to assess the relative high premium response then patent deep polymer arch on modified duplexer l tests should be done and we should rule out the pres they should be absence of stenotic or occlusive arterial lesions and dense calcification when we assess the weights barefoot means that we should access diameter with and without our tourniquet and uh if we are doing with tonic then for for four armed av diameter should be more than 2.5 mm for upper arm or av fishler the diameter should be more than 3mn and for graft it should be more than 4ml then we have to assess our patency we have to assess for compressibility we have to assess for dissensibility of a mean and we have to assess for absence of accessory means collecting near the side for av fish access and for central being we have to assess for respiratory physician so this is how the normal uh spectral waveform will be if you are accessing the proximal proximal to the anaesthetist in the artery if you are assessing artery distance to anesthosis and if you are assessing facial and in the framework so i will conclude by saying that the native if we visualize the vascular excess of choice for patients who require hemodialysis it lasts longer and is associated with fewer complications than other types of excess and for human dialysis association these benefits translate into the better quality of life and longer survival duplex ultrasound is fundamental for iodine 5 vessels that are suitable for creating an official av fish lab pre-operative mapping and for early detection of complications for surgery indeed the dopeless ultrasound is the only surveillance method that allows one to monitor av fish blood flow and simultaneously explore possible causes of vascular assay malformation and these facilities timely targeted salvage intervention that can provo from the survival of stiss and consequently that of the patient so with this i will end my talk and i will once again thanks all the delegates who have been listening patiently listening to this talk for the last uh 50 minutes or more thank you thank you sir uh that was a challenging topic dealt with ease along with excellent demonstrations using immediate confidence along with the rule of 6 and the talk concluded with the inclusion of the ultrasound factors for successful avf creation thank you uh what would you say is the learning curve to master this sir i i would say ussr 10 cases you are ready to go sir because because only concept is you you have to understand that once a facility is created the low resistance is the thing in spectral bonding that is important assessment criteria you have to do if it is acquisition for uh assessing an intervention in uh this dialysis first important is feel the thrill if the thrill is there good thrill is there so all intervention reduces they depend on this uh duplex ultrasound and duplex evaluation because that is the key any accessory or collateral that can be picked only easily using duplex ultrasound and then decision can be take how to tackle them how confidently you can associate accessory veins or as i told you the problem in more than 90 cases would be within first 10 centimeters from the anastomosis so we can very we easily assess this veins problem lies mostly in the first two centimeter of the of the anastomosis in the vein because these are the sides where you are doing repeated punctures a and b side so first entrance sentiment from the anus and these are easily accessible you can very well evaluate and with practice uh you you can confidently diagnose and very easy facility there the days easily uh the flow here is good for at least one two three sometimes sometimes as high as four to five years it depends on where the facility is created and when the first access was done it was the first mature the well end of the floor it was good and we do we said that at least at least after six weeks if the vehicle has not matured by six weeks that because this fish does not not uh used at least for one month after the fish decoration and if the fish is not uh matured in or in six years then we say it's a image of islam then it comes for evaluation overall formation so see see all always always surgeons start from the lower end from the tip towards the axilla they will first create the fish la here if if it's working if it plays then they will go higher so it's always in this direction not in the reverse direction see artery whatever what you are actually doing is you are nsmosing so if you have if it's not working here then only you have chance to make it work higher up what happens if you do for first switch recognition here here how can you you expect something to be functioning uh down the thing that's why you go from distal to proximal surgeon always preferred a distillery fish location it does not work then you have some other site of which the creation higher in this man it is not reverse and and always special for creation they always preferred the side of the artery and end of the [Music] and we provide a proper diagram then we will get a lot of reference for this because we will make the work easier for ourselves access planning including the [Music] yes sir definitely sir we will do sir as uh quite some time doing phenomenal work we all congratulate you all we appreciate and thanks to all delegates thank you thank you sir uh that was an ex interesting and excellent topic deal so meticulously and that was dr pankaj sharma associate professor from ames on the topic hemodialysis access shunt evaluation a great teacher from a premier institution thank you sir now now may i request dr amel anthony icri governing body member to propose a vote of thanks over to you sir thank you dr judy it's a pleasant task which i have and all those delegates who have been fortunate enough to log in i am sure would have benefited much from this excellent talk and we are in an era of turf expansion and this is one area which can be as he said you do 10 cases diligently under guidance and you are you are ready to go and this is one area which every radiologist who has got an access to a doctor ultrasound should be doing and and should be doing diligently and with lot of attention to the details as he has said and i'm sure that this will stimulate a lot of our young radiologists take to take this up because otherwise it's left to you know vascular surgeons or surgeons themselves or the nephrologists to do this so i am sure that radiologists can definitely pick this up because it's a simple thing as long as you understand the basic fundas as he has said so with these words let me thank dear friend pangat sharma for delivering this excellent talk which has benefited us all and it has been a great learning experience thank you pankaj on behalf of all of us here and on behalf of chris thank you thank you sir thank you and uh special thanks to dr keshudas who made the introductory remarks uh professor from srita institute of medical sciences and again a great academician who found time to uh to make the introductory remarks and make this session much more uh worthful uh thank you dr geshwadas and special thanks to professor emma baldwin who welcomed the gathering and who has been throughout here uh encouraging uh more young radiologists to join this session and i'm sure we'll be able to spread this word around more younger radiologists so that more and more people benefit from talks of this nature so thanks once again to all the delegates to join in and thanks to judy who did the comparing very well and also thanks to netflix for the support they have given so that we had a seamless presentation here and it's a wonderful platform uh absolutely different from the way we use other platforms so let's keep going and let's make the best out of everything the platform the technological support as well as the expertise which we are which is available now so thank you all or judy thank you sir just a few words just a few words before closing the recorded videos of the session will be added to the archives shortly on the same platform that is crest club participation certificates will be emailed to you within a few days if you have attended at least 75 percent of the program the the session recorded the video will be uploaded uploaded in crest club on the same platform after a few days now we are nearing the end of this evening session i appreciate the efforts of professor dr balachandra nyser dr mill anthony sir dr joe mathisa and dr ramesh shanoissa for all the support acknowledge the support of dr richard dr shubham mr lakshya and team of metrics for all the i.t related support finally thanking all the participants for attending all our programs

BEING ATTENDED BY

Dr. Sasikanth Reddy & 376 others

SPEAKERS

dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Pankaj Sharma

Dr. Pankaj Sharma

Associate Professor of Radiodiagnosis | AIIMS, Rishikesh

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Pankaj Sharma

Dr. Pankaj Sharma

Associate Professor of Radiodiagnosis | AIIMS...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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