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Hemodialysis Access Surveillance and Intervention
Keith B. Quencer, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        TERMINOLOGY

        • Definitions

          • Hemodialysis (HD)
            • Patient's blood is modified by going through dialyzer
              • Certain solutes are removed
                • e.g., potassium, phosphorus, and urea
              • Dialysate solutes are added
                • e.g., bicarbonate
              • Plasma water often removed
          • End-stage renal disease
            • a.k.a. chronic kidney disease (CKD) stage 5
            • Glomerular filtration rate (GFR) < 15 mL/min/1.73 m²
            • Need HD, peritoneal dialysis, or kidney transplant for medium-term survival
          • Arteriovenous fistula (AVF)
            • Surgical anastomosis between artery and vein
              • Results in dilation and arterialization of vein draining fistula
              • Requires maturation period before use
                • Typically 8- to 12-weeks maturation
                • ~ 50% never able to be used
              • Once mature, less infections and longer lifespan than arteriovenous grafts (AVGs)
            • Common types of AVF
              • Radiocephalic (RC) fistula (forearm)
                • Preferred dialysis access
                • Problem: Low rates of maturation
                • Typical site of stenosis: Juxtaanastomotic segment
              • Brachiocephalic fistula (upper arm)
                • 2nd preferred dialysis access
                • Used when radial artery or forearm cephalic vein are unsuitable for RC creation
                • Problems: High rate of dialysis-associated steal syndrome (DASS), precludes subsequent ipsilateral forearm fistula creation
                • Typical site of stenosis: Cephalic arch
              • Brachiobasilic fistula (upper arm)
                • Used when upper arm cephalic vein unsuitable for AVF creation
                • Problems: Difficult and 2-stage surgery, high rate of steal syndrome
                • Typical site of stenosis: Proximal swing segment
          • Mature fistula
            • Mature fistula is able to be repeatedly punctured and provide adequate flow for dialysis
            • Satisfies "rule of 6s"
              • Flow > 600 mL/min
              • Diameter > 0.6 cm
              • No more than 0.6 cm deep
              • Should be mature by 6 weeks
          • Immature fistula
            • Occurs in > 50% of newly created AVFs
              • Inflow stenosis
                • Most common cause of nonmaturation
                • Does not allow for dilation and arterialization of fistula
              • Competing outflow veins
                • Accessory veins: Naturally occurring branches arising from venous outflow tract; treat with ligation, embolization
                • Collateral veins: Alternative drainage pathways; develop in setting of downstream stenosis; treat by addressing underlying stenosis
              • Fistula that has failed to mature at 6 weeks should trigger further evaluation
          • AVG
            • Surgically created connection between artery and vein, using prosthetic conduit to provide vascular access for HD treatment
            • Used if unsuitable vascular anatomy for AVF
              • Suitable: Artery > 2 mm in diameter, vein > 2.5 mm in diameter
            • AVG has shorter lifespan than AVF
              • 6-10x greater infection risk and thrombosis
            • Polytetrafluoroethylene (PTFE) graft most frequently used AVG material
              • Can be used within 2-3 weeks of construction
              • Gore Acuseal able to be used 24 hr after creation
            • Types of AVG
              • Loop or straight configuration
                • Forearm preferred over upper arm
                • Arm preferred over groin
              • Prosthetic axillary-axillary arteriovenous straight access (necklace graft)
                • Used for patients with exhaustion of all other upper limb accesses but patent superior vena cava, subclavian and brachiocephalic veins
            • Typical site of stenosis: Graft-vein anastomosis
          • Cephalic arch
            • Most central portion of cephalic vein
              • Arches through deltopectoral groove to join axillary vein
            • Most frequent site of stenosis in dysfunctional brachiocephalic fistulas (40-77%)
              • Rarely cause of dysfunction in RC fistulas
            • Etiologies of stenosis
              • Extrinsic compression by clavipectoral fascia
              • High concentration of valves in this venous segment
              • Turbulence caused by sharp turn of arch combined with high flow rate
            • Difficult to treat
              • High-pressure balloons often needed
                • Associated high rate of vessel rupture
              • Low primary patency rate at 1 year (~ 20%) with angioplasty alone
          • Hemodialysis Reliable Outflow (HeRO) graft: Merit Medical
            • Arterial graft component
              • 6-mm inner diameter
              • Material: Expanded PTFE (ePTFE)
            • Venous outflow component
              • 5-mm inner diameter
              • Radiopaque silicone, reinforced with braided nitinol
            • Titanium connector between arterial graft and venous outflow
            • Used for failing AVF/AVG secondary to central venous stenosis
            • Catheter-dependent patients
            • Benefits
              • Lower infection compared to catheters
              • Improved HD adequacy compared to catheters
              • Higher patency rates compared to catheter
          • Qa: Access flow rate
            • Varies depending on access configuration, presence of stenosis, arterial inflow
          • Qb: Dialysis pump flow rate
            • Typically set at 350-400 mL/min
          • Kt/V: Number quantifying dialysis treatment adequacy
            • K: Dialyzer clearance of urea
            • T: Dialysis time
            • V: Volume of distribution of urea, approximately equal to patient's total body water
          • Monitoring: Periodic physical examination and review of routinely gathered data of dialysis patients performed to detect underdialysis and dysfunctional accesses prior to thrombosis
            • Weekly physical examination
            • Review of routinely gathered data collected during HD
              • Dialysis adequacy: Kt/V
                • Value < 1.2 or decrease by > 0.2 triggers referral for intervention
              • Dynamic pump pressures
                • Unreliable if taken in isolation
                • If abnormal trend, or with other access abnormalities, can be predictive of side of stenosis
            • Needling problems
              • Prolonged bleeding suggests outflow stenosis
              • Difficulty with cannulation suggests inflow stenosis
          • Surveillance: Instrument-based, periodic evaluation performed to detect underdialysis and dysfunctional accesses prior to thrombosis
            • Access flows
              • Measured by ultrasound dilution/conductance, dilution/thermal, dilution/Doppler
                • AVG < 600 mL/min or < 1,000 mL/min if > 25% drop → referral
                • AVF < 400 mL/min or < 1,000 mL/min if > 25% drop → referral
            • Static venous pressure
              • Useful in AVGs
                • Insensitive to detect inflow problems, which are more common in AVFs
              • Intraaccess pressure to mean arterial pressure (MAP) ratio > 0.5 triggers referral
            • Detection of recirculation
              • Occurs when Qa < Qb
                • Could be due to inflow or outflow problem
              • Recirculation > 10% triggers referral
              • Not sensitive surveillance technique AVGs
              • AVGs can thrombose with Qa < 600 mL/min
                • Recirculation occurs when flow rates are less than pump rates, typically set at 350-400 mL/min
            • Doppler ultrasound
              • Can measure flow rates, detect sites of stenosis
          • DASS
            • Arterial insufficiency ipsilateral to HD access
            • Risk factors
              • Diabetic patients with multiple prior shunts
              • Female sex
              • Brachial artery inflow
              • High-flow shunts/large anastomoses
              • Grafts (2.7-8.0%) more common than fistulas (< 2.0%)
            • Stages
              • Grade 1 (mild): Cool extremity but otherwise few symptoms
                • Distal flow augmentation with access occlusion
                • No treatment needed
              • Grade 2 (moderate): Intermittent ischemia
                • Pain during dialysis or with exercise
                • Treatment occasionally needed
              • Grade 3 (severe): Rest pain/tissue loss
                • Treatment mandatory, often with access ligation
          • National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI)
            • Provides multidisciplinary evidence-based clinical guidelines for CKD patients
              • Includes all stages of CKD and all aspects of care
            • Vascular access guidelines most relevant to interventional procedures

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Equipment Preparation

                    • Procedure Steps

                      • Findings and Reporting

                        • Alternative Procedures/Therapies

                          POST PROCEDURE

                          • Things to Do

                            • Things to Avoid

                              OUTCOMES

                              • Complications

                                • Expected Outcomes

                                  Selected References

                                  1. Niyyar VD et al: Clinical aspects of dialysis interventions: physical and sonographic findings. Semin Intervent Radiol. 39(1):9-13, 2022
                                  2. Pourmoussa AJ et al: Stent graft outcomes in dialysis circuits: a review of clinical trials and literature. Semin Intervent Radiol. 39(1):75-81, 2022
                                  3. Tabriz DM et al: Management of central venous stenosis and occlusion in dialysis patients. Semin Intervent Radiol. 39(1):51-5, 2022
                                  4. Liu C et al: Drug-coated balloon versus plain balloon angioplasty for hemodialysis dysfunction: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 10(23):e022060, 2021
                                  5. Yin Y et al: Efficacy and safety of paclitaxel-coated balloon angioplasty for dysfunctional arteriovenous fistulas: a multicenter randomized controlled trial. Am J Kidney Dis. 78(1):19-27.e1, 2021
                                  6. Lok CE et al: KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis. 75(4 Suppl 2):S1-164, 2020
                                  7. Lookstein RA et al: Drug-coated balloons for dysfunctional dialysis arteriovenous fistulas. N Engl J Med. 383(8):733-42, 2020
                                  8. Dinh K et al: Mortality after paclitaxel-coated device use in dialysis access: a systematic review and meta-analysis. J Endovasc Ther. 26(5):600-12, 2019
                                  9. Haskal ZJ et al: Prospective, randomized, concurrently-controlled study of a stent graft versus balloon angioplasty for treatment of arteriovenous access graft stenosis: 2-year results of the RENOVA study. J Vasc Interv Radiol. 27(8):1105-1114.e3, 2016
                                  10. Koirala N et al: Monitoring and surveillance of hemodialysis access. Semin Intervent Radiol. 33(1):25-30, 2016
                                  11. Sequeira A: Stent migration and bail-out strategies. J Vasc Access. 17(5):380-5, 2016
                                  12. Balaz P et al: True aneurysm in autologous hemodialysis fistulae: definitions, classification and indications for treatment. J Vasc Access. 16(6):446-53, 2015
                                  13. Maytham GG et al: The use of the early cannulation prosthetic graft (Acuseal™) for angioaccess for haemodialysis. J Vasc Access. 16(6):467-71, 2015
                                  14. Vasanthamohan L et al: The management of cephalic arch stenosis in arteriovenous fistulas for hemodialysis: a systematic review. Cardiovasc Intervent Radiol. 38(5):1179-85, 2015
                                  15. Agarwal AK et al: How should symptomatic central vein stenosis be managed in hemodialysis patients? Semin Dial. 27(3):278-81, 2014
                                  16. Hart D et al: Modification of the HeRO graft allowing earlier cannulation and reduction in catheter dependent days in patients with end stage renal disease: a single center retrospective review. ScientificWorldJournal. 2014:318629, 2014
                                  17. Modabber M et al: Central venous disease in hemodialysis patients: an update. Cardiovasc Intervent Radiol. 36(4):898-903, 2013
                                  18. Samett EJ et al: Augmented balloon-assisted maturation (aBAM) for nonmaturing dialysis arteriovenous fistula. J Vasc Access. 12(1):9-12, 2011
                                  19. Bittl JA: Catheter interventions for hemodialysis fistulas and grafts. JACC Cardiovasc Interv. 3(1):1-11, 2010
                                  20. Haskal ZJ et al: Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 362(6):494-503, 2010
                                  21. Monroy-Cuadros M et al: Risk factors associated with patency loss of hemodialysis vascular access within 6 months. Clin J Am Soc Nephrol. 5(10):1787-92, 2010
                                  22. Allon M et al: Hemodialysis vascular access monitoring: current concepts. Hemodial Int. 13(2):153-62, 2009
                                  23. Casey ET et al: Surveillance of arteriovenous hemodialysis access: a systematic review and meta-analysis. J Vasc Surg. 48(5 Suppl):48S-54S, 2008
                                  24. Gelbfish GA: Clinical surveillance and monitoring of arteriovenous access for hemodialysis. Tech Vasc Interv Radiol. 11(3):156-66, 2008
                                  25. Mauro MA et al: Image-Guided Interventions. 1st ed. Saunders, 2008
                                  26. Nassar GM: Endovascular management of the "failing to mature" arteriovenous fistula. Tech Vasc Interv Radiol. 11(3):175-80, 2008
                                  27. Rayner HC et al: Creation, cannulation and survival of arteriovenous fistulae: data from the dialysis outcomes and practice patterns study. Kidney Int. 63(1):323-30, 2003
                                  28. Gallego Beuter JJ et al: Early detection and treatment of hemodialysis access dysfunction. Cardiovasc Intervent Radiol. 23(1):40-6, 2000
                                  Related Anatomy
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                                  Related Differential Diagnoses
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                                  References
                                  Tables

                                  Tables

                                  KEY FACTS

                                  • Terminology

                                    • Preprocedure

                                      • Procedure

                                        TERMINOLOGY

                                        • Definitions

                                          • Hemodialysis (HD)
                                            • Patient's blood is modified by going through dialyzer
                                              • Certain solutes are removed
                                                • e.g., potassium, phosphorus, and urea
                                              • Dialysate solutes are added
                                                • e.g., bicarbonate
                                              • Plasma water often removed
                                          • End-stage renal disease
                                            • a.k.a. chronic kidney disease (CKD) stage 5
                                            • Glomerular filtration rate (GFR) < 15 mL/min/1.73 m²
                                            • Need HD, peritoneal dialysis, or kidney transplant for medium-term survival
                                          • Arteriovenous fistula (AVF)
                                            • Surgical anastomosis between artery and vein
                                              • Results in dilation and arterialization of vein draining fistula
                                              • Requires maturation period before use
                                                • Typically 8- to 12-weeks maturation
                                                • ~ 50% never able to be used
                                              • Once mature, less infections and longer lifespan than arteriovenous grafts (AVGs)
                                            • Common types of AVF
                                              • Radiocephalic (RC) fistula (forearm)
                                                • Preferred dialysis access
                                                • Problem: Low rates of maturation
                                                • Typical site of stenosis: Juxtaanastomotic segment
                                              • Brachiocephalic fistula (upper arm)
                                                • 2nd preferred dialysis access
                                                • Used when radial artery or forearm cephalic vein are unsuitable for RC creation
                                                • Problems: High rate of dialysis-associated steal syndrome (DASS), precludes subsequent ipsilateral forearm fistula creation
                                                • Typical site of stenosis: Cephalic arch
                                              • Brachiobasilic fistula (upper arm)
                                                • Used when upper arm cephalic vein unsuitable for AVF creation
                                                • Problems: Difficult and 2-stage surgery, high rate of steal syndrome
                                                • Typical site of stenosis: Proximal swing segment
                                          • Mature fistula
                                            • Mature fistula is able to be repeatedly punctured and provide adequate flow for dialysis
                                            • Satisfies "rule of 6s"
                                              • Flow > 600 mL/min
                                              • Diameter > 0.6 cm
                                              • No more than 0.6 cm deep
                                              • Should be mature by 6 weeks
                                          • Immature fistula
                                            • Occurs in > 50% of newly created AVFs
                                              • Inflow stenosis
                                                • Most common cause of nonmaturation
                                                • Does not allow for dilation and arterialization of fistula
                                              • Competing outflow veins
                                                • Accessory veins: Naturally occurring branches arising from venous outflow tract; treat with ligation, embolization
                                                • Collateral veins: Alternative drainage pathways; develop in setting of downstream stenosis; treat by addressing underlying stenosis
                                              • Fistula that has failed to mature at 6 weeks should trigger further evaluation
                                          • AVG
                                            • Surgically created connection between artery and vein, using prosthetic conduit to provide vascular access for HD treatment
                                            • Used if unsuitable vascular anatomy for AVF
                                              • Suitable: Artery > 2 mm in diameter, vein > 2.5 mm in diameter
                                            • AVG has shorter lifespan than AVF
                                              • 6-10x greater infection risk and thrombosis
                                            • Polytetrafluoroethylene (PTFE) graft most frequently used AVG material
                                              • Can be used within 2-3 weeks of construction
                                              • Gore Acuseal able to be used 24 hr after creation
                                            • Types of AVG
                                              • Loop or straight configuration
                                                • Forearm preferred over upper arm
                                                • Arm preferred over groin
                                              • Prosthetic axillary-axillary arteriovenous straight access (necklace graft)
                                                • Used for patients with exhaustion of all other upper limb accesses but patent superior vena cava, subclavian and brachiocephalic veins
                                            • Typical site of stenosis: Graft-vein anastomosis
                                          • Cephalic arch
                                            • Most central portion of cephalic vein
                                              • Arches through deltopectoral groove to join axillary vein
                                            • Most frequent site of stenosis in dysfunctional brachiocephalic fistulas (40-77%)
                                              • Rarely cause of dysfunction in RC fistulas
                                            • Etiologies of stenosis
                                              • Extrinsic compression by clavipectoral fascia
                                              • High concentration of valves in this venous segment
                                              • Turbulence caused by sharp turn of arch combined with high flow rate
                                            • Difficult to treat
                                              • High-pressure balloons often needed
                                                • Associated high rate of vessel rupture
                                              • Low primary patency rate at 1 year (~ 20%) with angioplasty alone
                                          • Hemodialysis Reliable Outflow (HeRO) graft: Merit Medical
                                            • Arterial graft component
                                              • 6-mm inner diameter
                                              • Material: Expanded PTFE (ePTFE)
                                            • Venous outflow component
                                              • 5-mm inner diameter
                                              • Radiopaque silicone, reinforced with braided nitinol
                                            • Titanium connector between arterial graft and venous outflow
                                            • Used for failing AVF/AVG secondary to central venous stenosis
                                            • Catheter-dependent patients
                                            • Benefits
                                              • Lower infection compared to catheters
                                              • Improved HD adequacy compared to catheters
                                              • Higher patency rates compared to catheter
                                          • Qa: Access flow rate
                                            • Varies depending on access configuration, presence of stenosis, arterial inflow
                                          • Qb: Dialysis pump flow rate
                                            • Typically set at 350-400 mL/min
                                          • Kt/V: Number quantifying dialysis treatment adequacy
                                            • K: Dialyzer clearance of urea
                                            • T: Dialysis time
                                            • V: Volume of distribution of urea, approximately equal to patient's total body water
                                          • Monitoring: Periodic physical examination and review of routinely gathered data of dialysis patients performed to detect underdialysis and dysfunctional accesses prior to thrombosis
                                            • Weekly physical examination
                                            • Review of routinely gathered data collected during HD
                                              • Dialysis adequacy: Kt/V
                                                • Value < 1.2 or decrease by > 0.2 triggers referral for intervention
                                              • Dynamic pump pressures
                                                • Unreliable if taken in isolation
                                                • If abnormal trend, or with other access abnormalities, can be predictive of side of stenosis
                                            • Needling problems
                                              • Prolonged bleeding suggests outflow stenosis
                                              • Difficulty with cannulation suggests inflow stenosis
                                          • Surveillance: Instrument-based, periodic evaluation performed to detect underdialysis and dysfunctional accesses prior to thrombosis
                                            • Access flows
                                              • Measured by ultrasound dilution/conductance, dilution/thermal, dilution/Doppler
                                                • AVG < 600 mL/min or < 1,000 mL/min if > 25% drop → referral
                                                • AVF < 400 mL/min or < 1,000 mL/min if > 25% drop → referral
                                            • Static venous pressure
                                              • Useful in AVGs
                                                • Insensitive to detect inflow problems, which are more common in AVFs
                                              • Intraaccess pressure to mean arterial pressure (MAP) ratio > 0.5 triggers referral
                                            • Detection of recirculation
                                              • Occurs when Qa < Qb
                                                • Could be due to inflow or outflow problem
                                              • Recirculation > 10% triggers referral
                                              • Not sensitive surveillance technique AVGs
                                              • AVGs can thrombose with Qa < 600 mL/min
                                                • Recirculation occurs when flow rates are less than pump rates, typically set at 350-400 mL/min
                                            • Doppler ultrasound
                                              • Can measure flow rates, detect sites of stenosis
                                          • DASS
                                            • Arterial insufficiency ipsilateral to HD access
                                            • Risk factors
                                              • Diabetic patients with multiple prior shunts
                                              • Female sex
                                              • Brachial artery inflow
                                              • High-flow shunts/large anastomoses
                                              • Grafts (2.7-8.0%) more common than fistulas (< 2.0%)
                                            • Stages
                                              • Grade 1 (mild): Cool extremity but otherwise few symptoms
                                                • Distal flow augmentation with access occlusion
                                                • No treatment needed
                                              • Grade 2 (moderate): Intermittent ischemia
                                                • Pain during dialysis or with exercise
                                                • Treatment occasionally needed
                                              • Grade 3 (severe): Rest pain/tissue loss
                                                • Treatment mandatory, often with access ligation
                                          • National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI)
                                            • Provides multidisciplinary evidence-based clinical guidelines for CKD patients
                                              • Includes all stages of CKD and all aspects of care
                                            • Vascular access guidelines most relevant to interventional procedures

                                        PREPROCEDURE

                                        • Indications

                                          • Contraindications

                                            • Preprocedure Imaging

                                              • Getting Started

                                                PROCEDURE

                                                • Patient Position/Location

                                                  • Equipment Preparation

                                                    • Procedure Steps

                                                      • Findings and Reporting

                                                        • Alternative Procedures/Therapies

                                                          POST PROCEDURE

                                                          • Things to Do

                                                            • Things to Avoid

                                                              OUTCOMES

                                                              • Complications

                                                                • Expected Outcomes

                                                                  Selected References

                                                                  1. Niyyar VD et al: Clinical aspects of dialysis interventions: physical and sonographic findings. Semin Intervent Radiol. 39(1):9-13, 2022
                                                                  2. Pourmoussa AJ et al: Stent graft outcomes in dialysis circuits: a review of clinical trials and literature. Semin Intervent Radiol. 39(1):75-81, 2022
                                                                  3. Tabriz DM et al: Management of central venous stenosis and occlusion in dialysis patients. Semin Intervent Radiol. 39(1):51-5, 2022
                                                                  4. Liu C et al: Drug-coated balloon versus plain balloon angioplasty for hemodialysis dysfunction: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 10(23):e022060, 2021
                                                                  5. Yin Y et al: Efficacy and safety of paclitaxel-coated balloon angioplasty for dysfunctional arteriovenous fistulas: a multicenter randomized controlled trial. Am J Kidney Dis. 78(1):19-27.e1, 2021
                                                                  6. Lok CE et al: KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis. 75(4 Suppl 2):S1-164, 2020
                                                                  7. Lookstein RA et al: Drug-coated balloons for dysfunctional dialysis arteriovenous fistulas. N Engl J Med. 383(8):733-42, 2020
                                                                  8. Dinh K et al: Mortality after paclitaxel-coated device use in dialysis access: a systematic review and meta-analysis. J Endovasc Ther. 26(5):600-12, 2019
                                                                  9. Haskal ZJ et al: Prospective, randomized, concurrently-controlled study of a stent graft versus balloon angioplasty for treatment of arteriovenous access graft stenosis: 2-year results of the RENOVA study. J Vasc Interv Radiol. 27(8):1105-1114.e3, 2016
                                                                  10. Koirala N et al: Monitoring and surveillance of hemodialysis access. Semin Intervent Radiol. 33(1):25-30, 2016
                                                                  11. Sequeira A: Stent migration and bail-out strategies. J Vasc Access. 17(5):380-5, 2016
                                                                  12. Balaz P et al: True aneurysm in autologous hemodialysis fistulae: definitions, classification and indications for treatment. J Vasc Access. 16(6):446-53, 2015
                                                                  13. Maytham GG et al: The use of the early cannulation prosthetic graft (Acuseal™) for angioaccess for haemodialysis. J Vasc Access. 16(6):467-71, 2015
                                                                  14. Vasanthamohan L et al: The management of cephalic arch stenosis in arteriovenous fistulas for hemodialysis: a systematic review. Cardiovasc Intervent Radiol. 38(5):1179-85, 2015
                                                                  15. Agarwal AK et al: How should symptomatic central vein stenosis be managed in hemodialysis patients? Semin Dial. 27(3):278-81, 2014
                                                                  16. Hart D et al: Modification of the HeRO graft allowing earlier cannulation and reduction in catheter dependent days in patients with end stage renal disease: a single center retrospective review. ScientificWorldJournal. 2014:318629, 2014
                                                                  17. Modabber M et al: Central venous disease in hemodialysis patients: an update. Cardiovasc Intervent Radiol. 36(4):898-903, 2013
                                                                  18. Samett EJ et al: Augmented balloon-assisted maturation (aBAM) for nonmaturing dialysis arteriovenous fistula. J Vasc Access. 12(1):9-12, 2011
                                                                  19. Bittl JA: Catheter interventions for hemodialysis fistulas and grafts. JACC Cardiovasc Interv. 3(1):1-11, 2010
                                                                  20. Haskal ZJ et al: Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 362(6):494-503, 2010
                                                                  21. Monroy-Cuadros M et al: Risk factors associated with patency loss of hemodialysis vascular access within 6 months. Clin J Am Soc Nephrol. 5(10):1787-92, 2010
                                                                  22. Allon M et al: Hemodialysis vascular access monitoring: current concepts. Hemodial Int. 13(2):153-62, 2009
                                                                  23. Casey ET et al: Surveillance of arteriovenous hemodialysis access: a systematic review and meta-analysis. J Vasc Surg. 48(5 Suppl):48S-54S, 2008
                                                                  24. Gelbfish GA: Clinical surveillance and monitoring of arteriovenous access for hemodialysis. Tech Vasc Interv Radiol. 11(3):156-66, 2008
                                                                  25. Mauro MA et al: Image-Guided Interventions. 1st ed. Saunders, 2008
                                                                  26. Nassar GM: Endovascular management of the "failing to mature" arteriovenous fistula. Tech Vasc Interv Radiol. 11(3):175-80, 2008
                                                                  27. Rayner HC et al: Creation, cannulation and survival of arteriovenous fistulae: data from the dialysis outcomes and practice patterns study. Kidney Int. 63(1):323-30, 2003
                                                                  28. Gallego Beuter JJ et al: Early detection and treatment of hemodialysis access dysfunction. Cardiovasc Intervent Radiol. 23(1):40-6, 2000