Change Concept #3
Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement

When possible, coordinate chronic kidney disease patient care so that patients will be referred early to surgeons specifically for AV fistula evaluation, including vein mapping where indicated, allowing sufficient lead-time for AV fistula maturation. Studies show that mapping vessels can significantly increase the incidence of successful AV fistulae (e.g., A strategy for increasing use of autogenous hemodialysis access procedures). Establish the understanding with your surgeons that they will contact you before placing anything other than an AV fistula. Where timing is such that a temporary access must be placed (e.g., catheter), arrange for evaluation (and placement, if feasible) of an AV fistula during the initial hospitalization.

• Perform an Appropriate Evaluation and Physical Exam Prior to Surgery Referral
• Refer Patients for Vessel Mapping
• Schedule Surgery with Sufficient Lead-Time for AV Fistula Maturation
• Communicate AV Fistula Expectations (Including Vessel Mapping) to Surgeons
• Place the AV Fistula at the Time of Hospitalization for Temporary Access

Frequently Asked Questions

Related Literature

Related Tools

Related Resources

Changes for Improvement:

Refer Patients for Vessel Mapping

Nephrologists should refer patients for vessel mapping (identification of vessel anatomy) where feasible, ideally prior to surgery referral. Doppler ultrasound or alternate technique should be used to search for suitable vessels that may be too deep to be identified on physical exam. Numerous studies have shown that vessel mapping identifies vessels suitable for an AV fistula in the majority of patients where physical exam alone classified the patient as not being a candidate for an AV fistula.

<< back

Schedule Surgery with Sufficient Lead-Time for AVF Maturation

In order to schedule surgery with sufficient lead-time for AV fistula maturation, nephrologists should refer patients to surgeons for "AVF only" evaluation no later than Stage 4 CKD (GFR<30).

<< back

Changes for Improvement:

Communicate AVF Expectations (including Vessel Mapping) to Surgeons

Nephrologists should establish an understanding with surgeons that all patients should be fully evaluated for the possibility of an AV fistula, including vessel mapping where necessary.

<< back