title: Estimation of brachial artery volume flow by duplex ultrasound imaging predicts dialysis access maturation.
abstract: OBJECTIVE
  This study validated duplex ultrasound measurement of brachial artery volume flow (VF) as predictor of dialysis access flow maturation and successful hemodialysis.
  
  
  METHODS
  Duplex ultrasound was used to image upper extremity dialysis access anatomy and estimate access VF within 1 to 2 weeks of the procedure. Correlation of brachial artery VF with dialysis access conduit VF was performed using a standardized duplex testing protocol in 75 patients. The hemodynamic data were used to develop brachial artery flow velocity criteria (peak systolic velocity and end-diastolic velocity) predictive of three VF categories: low (<600 mL/min), acceptable (600-800 mL/min), or high (>800 mL/min). Brachial artery VF was then measured in 148 patients after a primary (n = 86) or revised (n = 62) upper extremity dialysis access procedure, and the VF category correlated with access maturation or need for revision before hemodialysis usage. Access maturation was conferred when brachial artery VF was >600 mL/min and conduit imaging indicated successful cannulation based on anatomic criteria of conduit diameter >5 mm and skin depth <6 mm.
  
  
  RESULTS
  Measurements of VF from the brachial artery and access conduit demonstrated a high degree of correlation (R(2) = 0.805) for autogenous vein (n = 45; R(2) = 0.87) and bridge graft (n = 30; R(2) = 0.78) dialysis accesses. Access VF of >800 mL/min was predicted when the brachial artery lumen diameter was >4.5 mm, peak systolic velocity was >150 cm/s, and the diastolic-to-systolic velocity ratio was >0.4. Brachial artery velocity spectra indicating VF <800 mL/min was associated (P < .0001) with failure of access maturation. Revision was required in 15 of 21 (71%) accesses with a VF of <600 mL/min, 4 of 40 accesses (10%) with aVF of 600 to 800 mL/min, and 2 of 87 accesses (2.3%) with an initial VF of >800 mL/min. Duplex testing to estimate brachial artery VF and assess the conduit for ease of cannulation can be performed in 5 minutes during the initial postoperative vascular clinic evaluation.
  
  
  CONCLUSIONS
  Estimation of brachial artery VF using the duplex ultrasound, termed the "Fast, 5-min Dialysis Duplex Scan," facilitates patient evaluation after new or revised upper extremity dialysis access procedures. Brachial artery VF correlates with access VF measurements and has the advantage of being easier to perform and applicable for forearm and also arm dialysis access. When brachial artery velocity spectra criteria confirm a VF >800 mL/min, flow maturation and successful hemodialysis are predicted if anatomic criteria for conduit cannulation are also present.
authors.affiliation: Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, La Jolla, Calif.
authors.forename: Sae Hee
authors.initials: SH
authors.lastname: Ko
authors.affiliation: Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, La Jolla, Calif. Electronic address: dbandyk@ucsd.edu.
authors.forename: Dennis F
authors.initials: DF
authors.lastname: Bandyk
authors.affiliation: Department of Vascular Surgery, Kaiser Permanente Foundation, San Diego, Calif.
authors.forename: Kelley D
authors.initials: KD
authors.lastname: Hodgkiss-Harlow
authors.affiliation: Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, La Jolla, Calif.
authors.forename: Andrew
authors.initials: A
authors.lastname: Barleben
authors.affiliation: Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, La Jolla, Calif.
authors.forename: John
authors.initials: J
authors.lastname: Lane
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001783:Blood Flow Velocity; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D001916:Brachial Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000000981:diagnostic imaging; D011237:Predictive Value of Tests; D012039:Regional Blood Flow; D006435:Renal Dialysis; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D034941:Upper Extremity / Q000098:blood supply*