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What the European Guidelines Tell Us About Pre-Operative Vascular Access Imaging

By Susan Eymann, MS03 Jul 2019

In their comprehensive 2018 Clinical Practice Guidelines for Vascular Access the European Society for Vascular Surgery (ESVS) address pre-operative imaging for assessment of a vascular access. In addition to a detailed pre-operative history and physical examination, they accord non-invasive ultrasound imaging an important role in vascular access selection.

Citing Ferring’s 2010 study² at the UK’s Worcestershire Royal Hospital, the Guidelines states that pre-operative duplex ultrasound (DUS) enhances the success of creation and GettyImages-1126356458 (1)the outcome of autogenous AVFs. Another randomized trial demonstrated a primary failure rate of 6% when duplex ultrasound was used versus a failure rate of 25% when it wasn’t used.³ 

Ultrasound venous mapping allows a precise evaluation of the depth of vascular structures and detects vascular access sites that may be missed by clinical examination alone. Duplex ultrasound can measure arterial diameters and flow as well as reveal stenotic segments especially where physical tests (poor radial pulse, unsuitable forearm veins) suggest impaired arterial inflow. Moreover, duplex ultrasound imaging has been shown to identify patients with inadequate vessels in specific vascular access locations.⁴ 

In contrast, digital subtraction angiography (DSA) is helpful in only a small group of selected patients with significant peripheral vascular disease and suspected proximal arterial stenosis. The pre-operative endovascular approach allows identification and treatment in one procedure.

However, the risk of potential contrast induced nephropathy must be carefully considered if iodinated contrast is used. 

CE-MRA enables accurate pre-operative detection of upper extremity arterial and venous stenosis and occlusions. However, contrast enhanced magnetic resonance angiography (CE-MRA) is not recommended, since use of gadolinium is associated with the potential risk of a nephrogenic systemic fibrosis, especially in patients with severely impaired renal function.

Recommendation 11: “Contrast enhanced magnetic resonance angiography is not recommended in patients with end stage renal disease, because of the potential risk of gadolinium.”


  1. Schmidli J, et al., Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS), European Journal of Vascular and Endovascular Surgery (2018), p 13. 

  2. Ferring M, Claridge M, Smith SA, Wilmink T. Routine preoperative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis: a randomized trial. Clin J Am Soc Nephrol CJASN 2010;5:2236-44

  3. Mihmanli I, Besirli K, Kurugoglu S, Atakir K, Haider S, Ogut G, et al. Cephalic vein and hemodialysis fistula: surgeon’s observation versus color Doppler ultrasonographic findings. J Ultrasound Med 2001;20:217-224 

  4. Goldstein LJ, Gupta S. Use of the radial artery for hemodialysis access. Arch Surg 2003;138:1130-4.

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