I agree with Marc. I mark the access and send a color picture to the dialysis center as well as keeping one in the file and one to be kept by the patient. I also send ultrasound images of the depth of the vein in the cannulation zones. The dialysis centers ask for a picture if one is not sent. I am not certain who would be able to proctor the HDU staff as to how to use the ultrasound for cannulation. One must remember that many patients are cannulated by techs who may only have minimal training.

We have been doing the same kinds of marking and imaging. Given the chronic staffing challenges, it is a challenge to make any progress with the “cannulation coaching” in most dialysis units.

I have always thought that all fistulas may be used easily by everybody in the dialysis unit, with a low flow.
That means that I fight for easily usable fistulas. It is not always quick to obtain, but the peace is at the end of the goal.
That means obviously probably more transposition/lipectomy compared to other centers.
And generaly, I never recommend to use upper arm veins in case of a forearm fistula. They must be spared for a future elbow fistula.

Thierry - I agree that a fistula should be usable to cannulators with a wide range of expertise - the days when a surgeon can just bark about the units needing better cannulators are gone - we need to make accesses easier to use. BUT, I don't understand your point about avoiding upper arm veins developing from forearm fistulas so that they can be "saved" for a later upper arm fistula. I encourage the use of the cephalic vein above the antecubital fossa precisely to save the forearm fistula from excessive cluster cannulation, and to get better clearances from cannulation sites further apart. Unfortunately, this response mode does not allow me to attach images. I will have to create another post.