Ultrasound-guided cannulation of hemodialysis access
© The Author(s) 2016
Received: 28 August 2015
Accepted: 4 November 2015
Published: 19 February 2016
Because hemodialysis therapy cannot be performed without the cannulation of a vascular access, establishing a well-functioning vascular access is crucial. Recently, the number of patients with difficult arteriovenous (AV) fistula cannulation has increased due to changes in the epidemiology of the dialysis population. To address this issue, indications for real-time ultrasound-guided techniques have recently been reported. This review discusses methods of ultrasound-guided cannulation of dialysis access; it is difficult to cannulate a deep, small, or stiff vessel of an AV fistula on the first attempt with static ultrasound guidance in which the ultrasound probe remains stationary. Mastering a method in which the precise location of the needle tip can be continuously identified during the insertion by dynamic probe scanning is required. To achieve this, understanding the theory of ultrasound guidance, off/on-the-job training, and a sense of professionalism are important. The use of ultrasound also enables the safe catheter placement into a collapsed central vein and repeated direct puncture of a femoral vein. The latter reduces the risk of catheter-related blood stream infection by avoiding the use of an indwelling dual-lumen catheter. In conclusion, ultrasound-guided techniques enable precise vascular cannulation, which can result in significant patient and financial impact. The accumulation of further reports is required for the method to be acknowledged as the standard to cope with difficult vascular access for dialysis. As most of the latest ultrasound machines for procedural guidance are optimized for peripheral nerve block, a compact and affordable ultrasound device with image quality focused on vascular access is also needed.
KeywordsArteriovenous fistula Dynamic ultrasound guidance Vascular access Needle repositioning Internal jugular vein Guidewire Femoral vein Repeated cannulation Double-lumen catheter Point-of-care ultrasound
The creation and maintenance of a well-functioning vascular access are crucial for efficient hemodialysis therapy. The native arteriovenous (AV) fistula is widely recognized as the vascular access of first choice for most hemodialysis patients in that it has a lower frequency of complications compared with other types of vascular access [1–3]. In addition to an older age, female gender, and a history of diabetes, obesity was shown to be a significant risk factor for failure to achieve an AV fistula . As the KDOQI guideline states that a functional permanent access should be “less than 0.6 cm below the surface of the skin” , an AV fistula for obese patients may not be able to be cannulated with a traditional blind technique. On the other hand, the application of ultrasound-guided vascular access, which is now the standard in central venous access, has expanded to peripheral vessels [5–7]. Similarly, in the field of dialysis, there are growing indications for its use in cases of difficult peripheral dialysis vascular access, although the number of reports is still limited [8–11]. Even in Japan, where the prevalence of obesity is lower than in other countries, difficult AV fistula access has increased because of the epidemic of diabetes and aging of the dialysis population. Multiple access attempts result in poor patient satisfaction and unnecessary costs  and so must be avoided. Thus, as ultrasound-guided puncture in difficult AV fistula access is described in the recent Japanese vascular access guideline , this method has attracted attention. Furthermore, as a study on daily hemodialysis suggested, frequent cannulation can influence the patency of an AV fistula . An ultrasound-guided method may therefore have the potential to minimize AV fistula damage, resulting in a better prognosis for patients with difficult access. The aim of this review is to describe methods of ultrasound-guided cannulation of dialysis access and discuss conditions necessary for the methods to spread and help patients and dialysis providers avoid the problems of “poor access.”
Peripheral venous access (AV Fistula)
Unlike an AV graft, the accessibility of an AV fistula heavily depends on the condition of the patient’s autogenous vessel, which often leads to difficult access with the traditional blind technique. Although buttonhole cannulation can be an option for difficult access , ultrasound-guided needle insertion can address this problem. Even if the AV fistula is difficult to cannulate on the initial cannulation, it may become possible to cannulate it with the traditional method by the improvement of edema or maturation of an AV fistula while continuing dialysis therapy with ultrasound guidance. The indications of ultrasound-guided AV fistula cannulation are as follows: a vessel which is too deep or small for reliable cannulation, a vessel with an adjacent artery or nerve, a vessel with a history of frequent multiple attempts, and a vessel whose cannulation on the first attempt is vital.
Observe the target vessel thoroughly with ultrasound. Veins can be easily differentiated from arteries based on compressibility, pulsatility, shape, and knowledge of anatomy.
Sterilize the skin entry site and probe, and apply a tourniquet on the arm. A sterilized probe cover and ultrasound gel should be used.
Administer local anesthesia if necessary.
Place the probe directly above the vessel entry site so that the center of the target vessel is visualized in the center of the ultrasound screen and logically determine the entry site of the skin.
- 5.Insert the 5-mm end of the needle at the center of the probe, and then, keeping the probe orthogonal to the needle, move the probe backward to visualize the shaft image. Advance the probe forward and stop as soon as the bright spot has disappeared (Fig. 3). This point can be judged as the location of the needle tip. Subsequently, advance the needle and then identify the new location of the tip by moving the probe to-and-fro down the course of the vessel. If the trajectory of the shaft image misses the center of the target vessel, redirect the needle by angling it sideways. Repeat those steps until the needle tip is directly on the top of the vessel. Tenting of the anterior wall of the vessel is also a sign that the tip has reached the anterior wall.
Enter the vessel and visualize the bright spot within its lumen by advancing the probe carefully. (Although blood return may be noted at this time, it is ancillary information under ultrasound guidance as long as favorable imaging is being maintained.) While lowering the angle of the needle, advance the probe until the bright spot disappears within the vessel, and then advance the needle until the bright spot appears within it (an additional movie file shows this in more detail (see Additional file 2)). By repeating the above-described maneuver, guide the needle tip within the lumen of the vessel without touching the vessel’s inner wall. When using the catheter-over-needle method, advance the needle to the point where the tip of the catheter is well within the lumen of the vessel. Then, put the probe down and advance the catheter fully over the needle. Before advancing the catheter, the operator may ensure successful cannulation with a longitudinal image if needed . When a needle without a catheter is used, the tip should be guided to a final position; otherwise, it may go through the posterior or side wall of the vessel even after blood return is observed.
Longitudinal imaging is frequently used in ultrasound-guided peripheral nerve block . Under longitudinal imaging, an operator can see the entire length of the needle as it advances. However, as it is sometimes difficult to keep the center of the vessel perfectly aligned with the needle shaft within the thin ultrasound beam, small vessels can be very challenging using this imaging. Taken together, although still controversial from an evidence-based point of view, we support the use of transverse imaging as the main method and longitudinal imaging as an auxiliary method. However, even if large-scale randomized control studies facilitate a general consensus in the future, it may be fair to say that it is ultimately a personal choice because clinical settings and individual traits are quite diverse in reality. If a person feels satisfied with one method in particular, that is the main method to use.
Ultrasound-guided needle repositioning
In spite of its marked precision, it is not practical to apply ultrasound guidance to all AV fistulae because of a limited number of ultrasound machines, time, and labor. When placing a needle with the traditional method and the operator judges that the insertion is probably going to fail (i.e., no blood return, resistance to catheter advancement, etc.), then ultrasound guidance can be started to correct the needle tip location. Importantly, this not only prevents the failure of needle placement but also tells the operator why he or she almost failed . Thus, an ultrasound machine can be a good training tool for the traditional puncture method. Although there may be fear that introducing ultrasound machine use could erode traditional puncture skills, it depends on the attitude of the dialysis providers. Dialysis providers should continue to train themselves in both techniques. Of note, when ultrasound-guided needle repositioning is used, some kind of physical barrier, such as a dedicated cover, surgical gloves, film dressing, and commercially available plastic wrap , must be applied to the probe head to prevent potential cross-contamination between patients. However, as an experienced operator can perform the procedure without exposing the skin entry site to ultrasound gel, sterilized ultrasound gel is not always necessary.
Central venous access
Ultrasound is also useful in central venous cannulation in the field of hemodialysis, as discussed below.
Internal jugular vein
Because of its anatomical location, femoral venous access carries fewer risks of fatal mechanical complications than other types of central access. The femoral vein is preferred as an insertion site in emergency settings like orthopnea and shock, since this approach can be achieved comparatively easier and faster in critically ill bedridden patients. Disadvantages are high risks of infection and arterial puncture . Although there is a report that an ultrasound-guided technique significantly improved the success rate, reduced the number of attempts, and decreased the incidence of complications related to femoral venous dialysis catheter insertion , the first-attempt success rate under ultrasound guidance in this study was still 85 %. This is at least in part because femoral veins are located under a hyperechoic heterogeneous subcutaneous tissue, resulting in difficulty visualizing the needle tip directly on the ultrasound screen, like peripheral veins. The problem is that if one tries to increase the echogenicity of the needle shaft by adjusting the probe perpendicular to the needle, the image of the femoral vein becomes obscure as the angle of the needle is steep in the case of deep veins.
Simply using an ultrasound-guided technique does not necessarily mean safety . Naturally, training is required. There are three prerequisites for a training program: firstly, the theory of ultrasound-guided cannulation must be understood. Otherwise, the procedure would be intuitive, which cannot be a reliable method. In addition, a logical method is easier to learn than an intuitive one. Secondly, not only on-the-job training with an instructor but also off-the-job training with a simulator is essential. A recent meta-analysis showed that in comparison with no intervention, simulation training in health professionals’ education is associated with marked effects on knowledge, skills, and behaviors and moderate effects on patient-related outcomes . Thirdly, reflection after on-the-job training is necessary. Novice dialysis providers can educate themselves by looking back upon both good and bad aspects of their procedure. The reflection step can be effectively facilitated by watching the video of the ultrasound screen recorded during on-the-job training . Recently, a compact video recorder with the size of a matchbox is commercially available.
To make mock vessels, build tunnels through a hard, cuboid konjac jelly (traditional Japanese food available in grocery stores) by pressing a large straw into it.
Place the jelly in a tray whose depth is approximately the same as the thickness of the jelly.
Pour water into the tray until the top of the jelly is submerged.
Remove the air within the tunnels by squeezing the superior surface of the jelly with fingers.
Electromagnetic needle tracking systems which indicate the place where the needle tip will appear on an ultrasound screen under transverse imaging are available . However, these will not widely spread in dialysis therapy for the time being because of cost, precision, labor demands and the size of the equipment. Furthermore, even if under the use of those systems, expertise in sonoanatomy and reasonable needle handling skills are still mandatory, especially in the case of a small or collapsed vein. An ultrasound machine that is applicable to both central and peripheral veins in a dialysis room is considered to fall into the category of point-of-care ultrasound . Prerequisites for an ideal vascular access ultrasound machine are discussed below.
Size and durability
In some countries like Japan, most patients receive hemodialysis in bed. When a conventional console-style ultrasound machine is used, the installation site of the machine is limited because of the machine’s size and limited working space. In this situation, operators have to change their gaze during needle insertion, which makes the procedure ergonomically stressful. Although some facilities have utilized a head-mounted display  to overcome this issue, the size of an ultrasound machine should be compact so that it can be placed next to the patient on the bed. For patients receiving dialysis in a chair, a roll-away stand that can be easily attached and detached should also be available.
As ultrasound machines get smaller, there is a greater risk of them falling in busy dialysis facilities. Therefore, toughness is necessary.
For the safety reasons mentioned above, image quality that delineates a clear acoustic shadow is desirable so that a shaft is not mistaken for a tip under transverse imaging. In addition, high time-resolution is a prerequisite because needle jiggling, which is an essential technique in central venous access, does not work under low time-resolution imaging. Many of the latest ultrasound machines are installed with spatial-compound imaging where a couple of consecutive still image frames with different incident angles are averaged to improve spatial resolution . With this function turned on, time-resolution becomes impaired and the acoustic shadow is obscured. Therefore, it is better to turn the spatial-compound imaging off in vascular access.
Because most vascular access cannulations are done in a short period of time in typical hemodialysis facilities, introducing more than one ultrasound machine into a dialysis room would facilitate the smooth performance of daily routine work. Consequently, vascular access machines should be affordable.
Recently, some ultrasound machines have been installed with instruction images and videos of ultrasound-guided procedures. This is, however, not necessarily effective, because informative text books and instruction videos are readily available. Video output sockets (both digital and analog) are needed to record the ultrasound screen on video from an educational point of view, as stated in the “Training method” section.
First and foremost, creating a well-functioning vascular access and its maintenance are of the utmost importance. Needless to say, the traditional blind cannulation of a peripheral vascular access is a fundamental technique. Nevertheless, ultrasound-guided vascular access can be an effective method in continuing adequate hemodialysis therapy for some patients. The accumulation of further reports is required for the method to be acknowledged as the standard to cope with difficult AV fistula access.
Ultrasound-guided vascular access has three pillars: theory, off/on-the-job training, and an ultrasound machine optimized for vascular access. Among these, the former two require a strong sense of professionalism so that inserters achieve vascular access on the first attempt by any means. Finally, ultrasound machine manufacturers should realize that nerve block, which is performed exclusively under longitudinal imaging, and vascular access under transverse imaging are quite different in terms of their methodology. Therefore, a compact and affordable ultrasound machine with the image quality focused on vascular access is needed.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Feldman HI, Kobrin S, Wasserstein A. Hemodialysis vascular access morbidity. J Am Soc Nephrol. 1996;7:523–35.PubMedGoogle Scholar
- National Kidney Foundation. KDOQI 2006 vascular access guidelines. 2006. https://www.kidney.org/sites/default/files/docs/12-50-0210_jag_dcp_guidelines-va_oct06_sectionc_ofc.pdf. Accessed 2 Oct 2015.
- Kukita K, Ohira S, Amano I, Naito H, Azuma N, Ikeda K, et al. 2011 update japanese society for dialysis therapy guidelines of vascular access construction and repair for chronic hemodialysis. J Jpn Soc Dial Ther. 2011;44:855–938 (in Japanese).View ArticleGoogle Scholar
- Ethier J, Mendelssohn DC, Elder SJ, Hasegawa T, Akizawa T, Akiba T, et al. Vascular access use and outcomes: an international perspective from the dialysis outcomes and practice patterns study. Nephrol Dial Transplant. 2008;23:3219–26.PubMed CentralView ArticlePubMedGoogle Scholar
- Egan G, Healy D, O’Neill H, Clarke-Moloney M, Grace PA, Walsh SR. Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J. 2013;30:521–6.View ArticlePubMedGoogle Scholar
- Roberts J, Manur R. Ultrasound-guided radial artery access by a non-ultrasound trained interventional cardiologist improved first-attempt success rates and shortened time for successful radial artery cannulation. J Invasive Cardiol. 2013;25:676–9.PubMedGoogle Scholar
- Pittiruti M, Scoppettuolo G, Emoli A. Parenteral nutrition through ultrasound-placed piccs and midline catheters is associated with a low rate of complications: an observational study. Nutr Ther Metabol. 2009;27:142–8.Google Scholar
- Hanafusa N, Kondo Y, Kaneko T, Niwa T, Yamamoto H, Watanabe Y, et al. Vascular access puncture method with guidance by a portable ultrasonographic device. J Jpn Soc Dial Ther. 2007;40:517–21 (in Japanese).View ArticleGoogle Scholar
- Kamata T, Ochiai M, Osaki K, Fujisawa N, Kadoya Y, Yashiro M. Ultrasound-guided brachial venous cannulation as a novel venous needle site in hemodialysis patients. J Jpn Soc Dial Ther. 2011;44:237–43 (in Japanese).View ArticleGoogle Scholar
- Hanafusa N, Noiri E, Nangaku M. Vascular access puncture under ultrasound guidance. Ther Apher Dial. 2014;18:213–4.View ArticlePubMedGoogle Scholar
- Patel RA, Stern AS, Brown M, Bhatti S. Bedside ultrasonography for arteriovenous fistula cannulation. Semin Dial. 2015;28:433–4.View ArticlePubMedGoogle Scholar
- Lee T, Barker J, Allon M. Needle infiltration of arteriovenous fistulae in hemodialysis: risk factors and consequences. Am J Kidney Dis. 2006;47:1020–6.View ArticlePubMedGoogle Scholar
- Suri RS, Larive B, Sherer S, Eggers P, Gassman J, James SH, et al. Risk of vascular access complications with frequent hemodialysis. J Am Soc Nephrol. 2013;24:498–505.PubMed CentralView ArticlePubMedGoogle Scholar
- Wong B, Muneer M, Wiebe N, Storie D, Shurraw S, Pannu N, et al. Buttonhole versus rope-ladder cannulation of arteriovenous fistulas for hemodialysis: a systematic review. Am J Kidney Dis. 2014;64:918–36.View ArticlePubMedGoogle Scholar
- Myers K, Clough A. Making sense of vascular ultrasound. London: Arnold; 2004. p. 3–4.Google Scholar
- Nagdev A, LeVine S, Mantuani D. Point-of-care ultrasound. Philadelphia: Elsevier; 2015. p. 271–82.Google Scholar
- Kamata T, Ochiai M, Fujisawa N, Kadoya Y, Tomita M. Hemodialysis and portable ultrasound. J Kyoto City Hosp. 2012;32:1–7 (in Japanese).Google Scholar
- Garland SM, Newnan DM, de Crespigny LC. Plastic wrap for ultrasound transducers. Herpes simplex virus transmission. J Ultrasound Med. 1989;8:661–3.PubMedGoogle Scholar
- Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003;327:361.PubMed CentralView ArticlePubMedGoogle Scholar
- Adachi YU, Tuzuki M, Matsuda N. Is it constantly possible to penetrate only the anterior vessel wall against hydrostatic strain? Crit Care Med. 2012;40:2534–5.View ArticlePubMedGoogle Scholar
- Tokumine J. Manual of central venous catheterization using ultrasound guidance. Tokyo: Sogo Igaku sha; 2007. p. 26–7 (in Japanese).Google Scholar
- Blaivas M, Adhikari S. An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med. 2009;37:2345–9.View ArticlePubMedGoogle Scholar
- Stone MB, Nagdev A, Murphy MC, Sisson CA. Ultrasound detection of guidewire position during central venous catheterization. Am J Emerg Med. 2010;28:82–4.View ArticlePubMedGoogle Scholar
- Kamata T, Ochiai M, Fujisawa N, Kadoya Y. Visibility of guidewires in ultrasound-guided internal jugular double lumen catheterization. J Jpn Soc Dial Ther. 2012;45:475–82 (in Japanese).View ArticleGoogle Scholar
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123–33.View ArticlePubMedGoogle Scholar
- Prabhu MV, Juneja D, Gopal PB, Sathyanarayanan M, Subhramanyam S, Gandhe S, et al. Ultrasound-guided femoral dialysis access placement: a single-center randomized trial. Clin J Am Soc Nephrol. 2010;5:235–9.PubMed CentralView ArticlePubMedGoogle Scholar
- Kamata T, Shu S, Ochiai M, Osaki K, Fujisawa N, Kadoya Y, et al. Blood purification therapy using repeated ultrasound-guided femoral vein puncture: report of sixteen cases. J Jpn Soc Dial Ther. 2012;45:241–6 (in Japanese).View ArticleGoogle Scholar
- Blaivas M. Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central venous access. J Ultrasound Med. 2009;28:1239–44.PubMedGoogle Scholar
- Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011;306:978–88.PubMedGoogle Scholar
- Kamata T, Ochiai M, Fujisawa N, Kadoya Y, Tomita M, Okamura M. Simulation program for ultrasound-guided central venous access procedural training. J Jpn Soc Dial Ther. 2012;45:1027–33 (in Japanese).View ArticleGoogle Scholar
- Alessi S. Fidelity in the design of instructional simulations. Journal of Computor-Based Instruction. 1988;15:40–7.Google Scholar
- Kamata T. One-coin simulator for ultrasound-guided vascular access. The Japanese Journal of Dialysis and caring. 2010;19:6–7 (in Japanese).Google Scholar
- Choquet O, Abbal B, Capdevila X. The new technological trends in ultrasound-guided regional anesthesia. Curr Opin Anaesthesiol. 2013;26:605–12.View ArticlePubMedGoogle Scholar
- Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749–57.View ArticlePubMedGoogle Scholar
- Udani AD, Harrison TK, Howard SK, Kim TE, Brock-Utne JG, Gaba DM, et al. Preliminary study of ergonomic behavior during simulated ultrasound-guided regional anesthesia using a head-mounted display. J Ultrasound Med. 2012;31:1277–80.PubMedGoogle Scholar
- Szabo T. Diagnostic ultasound imaging: inside out. Burlington: Elsevier; 2004. p. 327–9.Google Scholar