Given that distal hypoperfusion may develop in the absence or presence of arterial stenoses, diagnostic arteriography of the extremity and the entirety of its inflow is a foundational part of the diagnostic evaluation prior to determining management. The subsequent choice of management may only be made after considering this diagnostic study. For example, a concomitant arterial stenosis may have a deleterious effect on a surgical procedure performed to treat the distal ischemia. Failure to recognize such stenoses may prove detrimental postsurgery. For example, in the presence of a hemodynamically significant arterial stenosis that is proximal to the arterial anastomosis of the access, a banding procedure employed to reverse the arterial steal may result in a perilous decline in blood flow through the access, possibly resulting in access thrombosis [133]. Fluoroscopy Fistulography Hemodialysis Access Area of Interest Leon et al [133] describes optimized arteriography as the most critical tool needed to facilitate the diagnosis of DASS or DHIS and support an appropriate treatment strategy. DSA supports effective visualization from the aortic arch to the palmar arch, allowing for detection of lesions in the more proximal arteries. Since steal from the distal vessels may be expected, DSA is performed with and without occlusion of the AV access. While the femoral artery has been used to perform diagnostic fluoroscopic arteriography in this setting, this evaluation may be performed simply by retrograde cannulation of the access with diagnostic catheter advancement into the aortic arch [133]. Given that an arterial stenosis may be an important contributor to distal ischemia, diagnostic fistulography via a percutaneous access has gained popularity in supporting management of DHIS. Valji et al [136] used arteriography to assess patients presenting with clinical findings of hand ischemia. They were able to image the entire arterial tree (ie, aortic arch to the palmar arch).
Dialysis Fistula Malfunction. Given that distal hypoperfusion may develop in the absence or presence of arterial stenoses, diagnostic arteriography of the extremity and the entirety of its inflow is a foundational part of the diagnostic evaluation prior to determining management. The subsequent choice of management may only be made after considering this diagnostic study. For example, a concomitant arterial stenosis may have a deleterious effect on a surgical procedure performed to treat the distal ischemia. Failure to recognize such stenoses may prove detrimental postsurgery. For example, in the presence of a hemodynamically significant arterial stenosis that is proximal to the arterial anastomosis of the access, a banding procedure employed to reverse the arterial steal may result in a perilous decline in blood flow through the access, possibly resulting in access thrombosis [133]. Fluoroscopy Fistulography Hemodialysis Access Area of Interest Leon et al [133] describes optimized arteriography as the most critical tool needed to facilitate the diagnosis of DASS or DHIS and support an appropriate treatment strategy. DSA supports effective visualization from the aortic arch to the palmar arch, allowing for detection of lesions in the more proximal arteries. Since steal from the distal vessels may be expected, DSA is performed with and without occlusion of the AV access. While the femoral artery has been used to perform diagnostic fluoroscopic arteriography in this setting, this evaluation may be performed simply by retrograde cannulation of the access with diagnostic catheter advancement into the aortic arch [133]. Given that an arterial stenosis may be an important contributor to distal ischemia, diagnostic fistulography via a percutaneous access has gained popularity in supporting management of DHIS. Valji et al [136] used arteriography to assess patients presenting with clinical findings of hand ischemia. They were able to image the entire arterial tree (ie, aortic arch to the palmar arch).