Role of multimodality imaging pre-access for planning of surgical creation of arteriovenous fistulas and arteriovenous grafts in the chronic kidney disease and end-stage renal disease population.

Abstract

This review explores a range of imaging techniques used in the pre-surgical planning of vascular access, including duplex ultrasound (DUS), digital subtraction angiography (DSA), digital subtraction venography (DSV), CO2 Venography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), and Intravascular ultrasound (IVUS). For each modality, we analyze its technical background, applications, advantages and disadvantages, and comparisons with alternative imaging options. DUS is the most widely used imaging modality in pre-surgical planning due to its low cost, non-invasiveness, absence of ionizing radiation and nephrotoxic contrast agents, and comparable accuracy in pre-access mapping with other methods. DSA and DSV have high sensitivity and specificity to visualize the arterial and venous system and are recommended when central vascular stenosis is suspected, or a simultaneous intervention is anticipated. However, their use is limited due to exposure to contrast agents and ionizing radiation. CO2-based contrast agents provide an alternative for end-stage renal disease (ESRD) patients to preserve residual renal function. MRA provides a noninvasive option with no radiation exposure and superior image resolution, yet the high cost and limited availability restrict their widespread clinical use. CTA, with its short acquisition time and high-resolution imaging, is a vital modality in intricate cases. However, radiation and contrast exposure can pose challenges in this patient population. The newer IVUS modality has a superior ability to central venous outflow obstruction compared to DSA and provides more information regarding vascular geometry and anatomy. Each imaging modality has its unique advantages and disadvantages in this patient cohort. The decision to use a particular imaging must be made on a case-to-case basis. However, following KDOQI guidelines, a combination of a patient's medical history, physical examination, and DUS is a widely accepted standard practice in pre-surgical vascular access planning, with other imaging modalities reserved for selected patients.