I have always thought that the surgeon ought to give an easy to puncture vascular access to the patients. It is obvious that in some cases, US is very useful, but this must not lead to bad quality VA, with the commentary: It is going to be easy to use with US!
In some centers in France, we face now the problem of a rapid turn over of nurses, with the difficulty to use even very obvious fistulas.
Thierry POURCHEZ, FRANCE

Hello Debbie.
Its all about the economics and how well we could train the staff. I think not all staff need to be trained; just one or 2 on any work shift for the more difficult accesses. As I have previously shown that a surgeon's map of the access (A PHOTOGRAPH) makes a great deal of DIFFERENCE IN CANNULATION SUCCESS

Anatole BESARAB

Thanks for bringing this up, Debbie. I strongly support this, and @ Emory, we have our vascular access team trained in US and they are present for all first cannulations of new AVF, and map out the access for subsequent use by the canulation team. We have submitted our data as an abstract for the ASDIN meeting. And it is relatively easy to teach - I agree with Dr. Besarab - you just need to teach a couple of "champions" and it propagates. There are many hand-held inexpensive devices out there, so in the big scheme of things, cost is not really a factor.- the limitation is the time.

This is an on-going problem, especially with first cannulations. I think if ultrasound is required at the HDU, then the access is problematic. Our issue has always been who will train the HDU staff and maintain the staff’s accreditation for ultrasound-guided access cannulation? I do like the idea of having a point and see device as it would stop the “I cannot feel the access’s bruit, so I will place a needle just to make certain it is thrombosed” methodology at the HDU. I always drew on the access with a sharpie with cannulation points as well as an ultrasound map and a color picture to place in the patient’s file at the HDU. I do think there should be cannulation champions at all HDUs. When we limited the cannulation of new accesses to only a few techs as well as requiring that the same one or two techs for the first 2-3 months, our infiltration rate plummeted when compared to the practice habits before the change. Also, some centers have said that all of their techs are equivalent in his/her skills. We all know that that is absolutely not true. What a great discussion. I would love to hear more ideas.

For deep, poorly differentiated AVFs I often start button holes . I often canulate initially under US, then dilate with 7-8 Fr dilators and have HDUs use them right away. I have a pretty good success with this. Often these AVFs become more defined with time, then sharp canulations can be restarted when needed. Drawing on the arm, sending diagrams never really worked for my local units. I think canulation is more of a touch and feel thing rather than visual -with exception of using US, if you are good in it. I think it would take long time to train my local HDU staff. For now button holes is the solution

I agree that dialysis access cannulation is a tactile art. If the dialysis nurse cannot feel the vein, then the patient needs a procedure. Maybe angioplasty, maybe superficialization, maybe transposition, maybe straightening, maybe ligation of parallel branches, maybe accessory vein ligation. I always mark arms, but even this is of limited utility. The skin rolls over the veins or doesn't lie over the vein when the arm is positioned differently or the tourniquet is applied. The marking just gets the nurse in the ballpark. Ultrasound is often more damaging than good, as it is very operator dependent. Even after many years of using ultrasound, I will try to stick a small fistula or clotted access, only to see the needle rolling off the sides of the vein or no success. Many times I just drop the ultrasound, and go by tactile sense,

I honestly think the answer lies with better education of the dialysis cannulators regarding best practice techniques; such as rope ladder cannulation and applying a tourniquet (not just finger pressure), placement of a TDC to go 1&1 if needed, or prompt revision of problematic fistula, than putting ultrasound machines in the Dialysis Unit. At least in the US, outpatient unit cannulators have minimal training and are not LPN/RN level

Although I always appreciated buttonholes, the risk for infection is always a concern. I marveled at how home dialysis patients rarely had infections versus the HDU cannulators. I am not trying to bash the HDUs, but that was my experience. This was a complication that no one wanted.
I have a picture that will not paste. I am not certain what the correct answer is.

I am amazed at the comments made so far, all by people I know to be real experts in dialysis access. We've seen about every reason in the book to NOT encourage use of ultrasound to help nurses guide needles into fistulas. These comments are by skilled physicians who would never think of evaluating a graft or fistula in an access center, without having a high quality ultrasound machine available. Why would we not want to provide the same tool that we rely upon to nurses, especially for fistulas that have never been accessed before, or are known to be difficult to stick?

Dr. Ash, I agree with you. I am just relating the issues that we incurred at the HDUs. No one wanted to pay for the ultrasound or for training. It was much like the battle over surveillance in the HDUs. I would prefer the ultrasound in the HDUs to the multiple cannulation attempts at a dysfunctional fistula. I do think what people are saying is that there is not a single answer to this problem. Also, that answer may be region-specific.

A big question here is what is acceptable SIGMA here and if that justifies what you do.
Financial costs of the device and upfront investment notwithstanding, I can't see how this can have a meanigful impact at least in our market with full employment and a hight nursing and PCT turnover. A very good tool given to inexperienced hands could be not only be futile but potentially imperil the care.. Poor technique is not the sole factor leading to infiltration in our population. Back to rule of "six" along with infrequent occurrence of overlying accessories would cover most of the issues IMHO..
In almost all the cases, if our team (our great surgeons, RN, Providers) feel high probability of unsuccessful outcome or an actual bad event, we perform ultrasound and mark the "safe zones", avoid /deal with accessories or address any other underlying problems. It has successfully worked and we generally don't any issues with infiltration again other than "new/unexperienced hands.

The purpose of the hand held "point and see" ultrasound is to allow the PCT or nurse to see the depth of the AVF or AVG as that determines the needle angle. It also is used to show the path of the vessel so the staff are not inserting the needle into an area where once the 1" needle is advanced- it is not in a straight part of the vessel. It can also help with the needle gauge with a simple check of the vessel diameter. The multiple pilots done in the dialysis units used the B mode so the staff could see the path for the needle advancement. It is not diagnostic in any way. Just to help find the proper cannulation area. Many facilities have a Vascular Access Manger or Coordinator. This role onw includes ultrasound use for cannulation in many facilities outside the US. Training of the simple devices typically take only a half day of theory and then use on patients pre dialysis. Can even be done as the wait for their chair to be ready to prevent any treatment delays. It is now being used widely as the standard of care in for profit units outside the us along with hospital and non-profit facilities. I have been screamed at for years by surgeons asking why the staff don't have ultrasound- the reason in the past was the training issues. The newer devices resolve the training issues and the cost is lower than the diagnostic units all of you have in your practices. The use of the device helped the staff to visual what is under the skin. The patients also get to see the images. It impowered both the staff and patients to maximize the cannulation zones (true rope ladder) as they can see the vessel depth, size and path. Hope that makes this a bit more clear.

I absolutely support the idea of using an ultrasound to assist in the cannulation of AV fistulas and grafts at hemodialysis units

At our vascular access Center here we have the saying "the ultrasound never lies" when it comes to vascular access. We would never think of accessinga vessel without the assistance of a vascular ultrasound.

This is a tool that should be made available at the dialysis units.More so that the evidence is out there.

Havingnow created a few of the endovascular av fistulas using The WavelinQ technology a few weeks ago, we have observed on follow up, that a large number of this fistulas have split flow into the upper arm. Ultrasound assistance in cannulation will likely increase the success.

In fact, we are working on partneiring with the dialysis provider teams in training the staff on cannulations and one of the issues our team is planning to bring up is the use of ultrasound.

Thank you,

Alejandro Alvarez, MD

I have provided an 8 x 11 glossy photo of every released fistula with the fistula sketched on the photo since 2001. Course, size, depth, branches and valves are all marked, along with suggestions/directions for use.

Mark the valves on the photo? Why would we care where the valves are?