Approximately, 550,000 patients with end-stage kidney disease rely on maintenance dialysis in the United States, and nearly 90% receive hemodialysis.[1] Providing hemodialysis requires a conduit to the bloodstream (vascular access) that can reliably deliver a high blood flow into the extracorporeal dialysis circuit. A surgical arteriovenous fistula (AVF) is created by a direct surgical anastomosis between a peripheral artery and vein. AVFs are considered the preferred type of vascular access, because they have better survival and require fewer interventions to maintain long-term patency for dialysis, once they are successfully cannulated for dialysis.[2] [3] [4]

A prerequisite for the successful cannulation of an AVF for dialysis is the progressive increase in the diameter and blood flow of the draining vein observed over the first 6 postoperative weeks.[5] This physiologic process, termed AVF maturation, fails to occur in a substantial proportion of surgical AVF (sAVF).[6] [7] Non-maturation of an sAVF may lead to subsequent interventions to promote maturation, which, when unsuccessful, results in sAVF abandonment.

Percutaneous AVF (pAVF) is a novel percutaneous technique for AVF creation, with several devices recently approved for use in the United States by the Food and Drug Administration (FDA).[8] [9] Surgically created AVFs typically have an up to 90-degree angle of the vein with the artery at the end-to-side anastomosis. Computational fluid dynamics suggest that an anastomotic angle of less than 30 degrees improves the flow hemodynamics, and pilot clinical data demonstrated that a smaller surgical anastomotic angle reduced juxta-anastomotic stenosis.[10] [11] [12] In contrast to the surgical technique, an endovascular approach potentially minimizes vascular injury at the time of AVF creation by creating a channel between the artery and vein with an angle approaching 0 degrees (side to side anastomosis). The narrower vein–artery angle in a pAVF provides a potential rationale for superior maturation, as compared with a sAVF. However, the creation of a pAVF requires several additional vascular measurements in addition to those needed for sAVF.

Percutaneous access creation requires a more extensive preprocedural sonographic evaluation of antecubital and upper forearm anatomy, not needed for sAVF creation. The following is a standardized method of sonographic mapping prior to surgical and percutaneous hemodialysis AVF creation, highlighting pertinent anatomic variations as well as technical and interpretive challenges.

Article published online:
04 May 2023

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