1993, The British Journal of Radiology, 66, 32-36 Imaging of dialysis access: a review of 67 failing fistulas investigated by intravenous digital subtraction angiography R E M ENGLAND, FRCR and A JACKSON, PhD, MRCP, FRCR Department of Neuroradiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK Abstract We have reviewed 67 failing haemodialysis fistulas imaged by intravenous digital subtraction angiography (IVDSA). Peripheral venous injection of non-ionic contrast was used in all examinations. No complications relating to peripheral injection, contrast dose or fluid load were experienced. Image quality was poor, owing to inadequate vascular opacification, in 1/67. Image quality was excellent (53/67), or good (13/67) in the remaining 66. 56/66 of these examinations were diagnostic. Diagnoses included abnormalities of feeding arteries, anastomoses, draining veins, and central veins. Multiple abnormalities were demonstrated in 10/56 examinations. Conventional arm venography was performed in addition to IVDSA infivecases where venous images were inadequate owing to anastomotic obstruction (3/5) or poor opacification (2/5). 5/66 examina- tions were non-diagnostic owing to failure to image the central veins where no cause for fistula failure had been demonstrated. A further 5/66 examinations were non-diagnostic owing to failure to obtain oblique projections of the shunt where vascular details was obscured by overlapping vessels. The authors recom- mended routine imaging of the dialysis shunt in two planes and central venous imaging in all cases. This would have resulted in reduction of the failure rate from 16% to 1.5% in this series. IVDSA using a peripheral injection technique is simple, free from complications, and provides good quality images of both arterial and venous components of the fistula. Images of vessels not directly involved in fistula formation are routinely obtained and aid the planning of fistula revision. Keywords: Haemodialysis, Digital imaging, Angiography, A-V fistulae Loss of vascular access is a major cause of morbidity (less than 150 ml min" 1 ) (Gilula et al, 1975). Failure of in patients on long term haemodialysis. Since the work fistula maturation, distal or regional ischaemia and the of Brescia et al (1966), internal arterio-venous fistulae formation of aneurysms at venous puncture sites are have become the method of choice for vascular access in also common problems. Radiological investigation is all dialysis centres. Arterio-venous shunting is most required to identify the causes of fistula failure and to commonly achieved by the original Brescia-Cimino provide anatomical information prior to surgical revi- technique, producing direct anastomosis of the radial sion (Thomsen & Stenport, 1985; Bursztyn et al, 1986). artery to the adjacent cephalic vein. Where a No fully satisfactory technique currently exists for the Brescia-Cimino fistula is impractical an arterio-venous investigation of failing vascular access and there is a fistula may be formed using an arterio-venous graft in wide variation in the methods recommended in the the forearm or antecubital fossa. Graft materials may be literature (Gilula et al, 1975; Glanz et al, 1982; Boomsa biological (autologous or heterologous venograft) or et al, 1984; Langer et al, 1984; Thomsen & Stenport, artificial, most commonly polytetrafluouroethylene 1985; Allen et al, 1986). In our centre we have used the (PTFE) (Thompson et al, 1972; Giacchino et al, 1979; technique of intravenous digital subtraction angio- Hunter & So, 1987). During the 3-6 weeks following graphy (IVDSA) following peripheral venous injections fistula formation the fistula will "mature", a thrill of contrast, as a first line investigation. The results of develops in the draining vein, the feeding artery and five years' experience with this technique are presented, draining vein dilate and the vein wall thickens and "arterializes", allowing repeated puncture for dialysis. Patients and me thods All arterio-venous fistulas are prone to multiple compli- M haemodialysis patients referred for imaging of cations, most commonly vascular stenoses or throm- ^ fistulas were induded i n t h e stud The indica . boses, resulting in an inadequate blood flow for dialysis tiong for investigation inc i uded fai i ure o f shunt matu- ration (2/67), symptoms of insufficient circulation distal Received 26 February 1992 and in revised form 27 August to the shunt (steal syndrome, 3/67), swelling of the shunt 1992, accepted 14 September 1992. extremity suggesting central venous occlusion (3/67), 32 The British Journal of Radiology, January 1993