Dialysis Fistula Malfunction

Variant: 1 Suspected dysfunction of upper or lower extremity hemodialysis access (ie, arteriovenous fistula or graft) suggested by an abnormal clinical indicator or hemodynamic indicator (ie, reduction in dialysis vascular access blood flow rate or kinetics). Initial imaging to guide interventional radiologic therapy options.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access area of interest	Usually Appropriate	☢☢☢
US duplex Doppler hemodialysis access area of interest	Usually Appropriate	O
MRA extremity area of interest without IV contrast	Usually Not Appropriate	O
CTA extremity area of interest with IV contrast	Usually Not Appropriate	Varies
CTV extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRA extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without IV contrast	Usually Not Appropriate	O

Variant: 2 Suspected dysfunction of the upper or lower extremity hemodialysis access (ie, arteriovenous fistula or graft) suggested by an abnormal clinical indicator or hemodynamic indicator (ie, reduction in dialysis vascular access blood flow rate or kinetics). Treatment and procedures.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access with intervention	Usually Appropriate
US duplex Doppler hemodialysis access area of interest	Usually Appropriate	O
Surgical consultation	May Be Appropriate
Continued hemodialysis access use with surveillance	May Be Appropriate
Placement of a new tunneled dialysis catheter	May Be Appropriate

Variant: 3 Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Initial imaging to guide interventional radiologic therapy options.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access area of interest	Usually Appropriate	☢☢☢
US duplex Doppler hemodialysis access area of interest	May Be Appropriate	O
CTA extremity area of interest with IV contrast	Usually Not Appropriate	Varies
CTV extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRA extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRA extremity area of interest without IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without IV contrast	Usually Not Appropriate	O

Variant: 4 Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Treatment and procedures.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access with intervention	Usually Appropriate
Surgical consultation	Usually Appropriate
Placement of a new tunneled dialysis catheter	May Be Appropriate
US duplex Doppler hemodialysis access area of interest	Usually Not Appropriate	O

Variant: 5 Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access area of interest	Usually Appropriate	☢☢☢
US duplex Doppler hemodialysis access area of interest	Usually Appropriate	O
CTV extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRA extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRA extremity area of interest without IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without and with IV contrast	Usually Not Appropriate	O
CTA extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRV extremity area of interest without IV contrast	Usually Not Appropriate	O

Variant: 6 Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Treatment and procedures.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access with intervention	Usually Appropriate
Surgical consultation	Usually Appropriate
US duplex Doppler hemodialysis access area of interest	Usually Appropriate	O
Placement of a new tunneled dialysis catheter	May Be Appropriate

Variant: 7 Clinical suspicion of central venous stenosis or occlusion suggested by swelling (ie, soft tissue edema) of the extremity ipsilateral to the upper or lower extremity hemodialysis access, with or without the development of venous collaterals. Initial imaging to guide interventional radiologic therapy options.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access area of interest	Usually Appropriate	☢☢☢
CTA extremity area of interest with IV contrast	Usually Not Appropriate	Varies
CTV extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRA extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRA extremity area of interest without IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without IV contrast	Usually Not Appropriate	O
US duplex Doppler hemodialysis access area of interest	Usually Not Appropriate	O

Variant: 8 Clinical suspicion of central venous stenosis or occlusion suggested by swelling (ie, soft tissue edema) of the extremity ipsilateral to the upper or lower extremity hemodialysis access, with or without the development of venous collaterals. Treatment and procedures.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access with intervention	Usually Appropriate
Continued hemodialysis access use with surveillance	May Be Appropriate
US duplex Doppler hemodialysis access area of interest	Usually Not Appropriate	O
Placement of a new tunneled dialysis catheter	Usually Not Appropriate
Surgical consultation	Usually Not Appropriate

Variant: 9 Abnormal skin changes associated with the upper or lower extremity hemodialysis access cannulation site, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial or deep infection. Initial imaging to guide interventional radiologic therapy options.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler hemodialysis access area of interest	Usually Appropriate	O
Fluoroscopy fistulography hemodialysis access area of interest	May Be Appropriate	☢☢☢
CTV extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRA extremity area of interest without and with IV contrast	Usually Not Appropriate	O
CTA extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRA extremity area of interest without IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without IV contrast	Usually Not Appropriate	O

Variant: 10 Abnormal skin changes associated with the upper or lower extremity hemodialysis access cannulation site, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial or deep infection. Treatment and procedures.

Procedure	Appropriateness Category	Relative Radiation Level
Surgical consultation	Usually Appropriate
Placement of a new tunneled dialysis catheter	Usually Appropriate
Fluoroscopy fistulography hemodialysis access with intervention	May Be Appropriate
Continued hemodialysis access use with surveillance	Usually Not Appropriate

Variant: 11 Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy fistulography hemodialysis access area of interest	Usually Appropriate	☢☢☢
US duplex Doppler hemodialysis access area of interest	Usually Appropriate	O
CTA extremity area of interest with IV contrast	May Be Appropriate	Varies
CTV extremity area of interest with IV contrast	Usually Not Appropriate	Varies
MRA extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRA extremity area of interest without IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without and with IV contrast	Usually Not Appropriate	O
MRV extremity area of interest without IV contrast	Usually Not Appropriate	O

Variant: 12 Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.

Procedure	Appropriateness Category	Relative Radiation Level
Surgical consultation	Usually Appropriate
Continued hemodialysis access use with surveillance	May Be Appropriate
Fluoroscopy fistulography hemodialysis access with intervention	May Be Appropriate
Placement of a new tunneled dialysis catheter	May Be Appropriate
US duplex Doppler hemodialysis access area of interest	Usually Not Appropriate	O

Panel Members

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Suspected dysfunction of upper or lower extremity hemodialysis access (ie, arteriovenous fistula or graft) suggested by an abnormal clinical indicator or hemodynamic indicator (ie, reduction in dialysis vascular access blood flow rate or kinetics). Initial imaging to guide interventional radiologic therapy options.

Variant 2: Suspected dysfunction of the upper or lower extremity hemodialysis access (ie, arteriovenous fistula or graft) suggested by an abnormal clinical indicator or hemodynamic indicator (ie, reduction in dialysis vascular access blood flow rate or kinetics). Treatment and procedures.

Variant 3: Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Initial imaging to guide interventional radiologic therapy options.

Variant 4: Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Treatment and procedures.

Variant 4: Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Treatment and procedures.
A. Fluoroscopy Fistulography Hemodialysis Access with Intervention

Variant 4: Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Treatment and procedures.
D. US Duplex Doppler Hemodialysis Access Area of Interest

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
A. Fluoroscopy Fistulography Hemodialysis Access Area of Interest

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
B. US Duplex Doppler Hemodialysis Access Area of Interest

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
C. CTA Extremity area of Interest With IV Contrast

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
D. CTV Extremity Area of Interest With IV Contrast

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
E. MRA Extremity Area of Interest Without and With IV Contrast

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
F. MRA Extremity Area of Interest Without IV Contrast

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
G. MRV Extremity Area of Interest Without and With IV Contrast

Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
H. MRV Extremity Area of Interest Without IV Contrast

Variant 6: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Treatment and procedures.

Variant 6: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Treatment and procedures.
A. Fluoroscopy Fistulography Hemodialysis Access with Intervention

Variant 6: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Treatment and procedures.
B. Surgical Consultation

Variant 6: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Treatment and procedures.
C. Placement of a New Tunneled Dialysis Catheter

Variant 6: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Treatment and procedures.
D. US Duplex Doppler Hemodialysis Access Area of Interest

Variant 7: Clinical suspicion of central venous stenosis or occlusion suggested by swelling (ie, soft tissue edema) of the extremity ipsilateral to the upper or lower extremity hemodialysis access, with or without the development of venous collaterals. Initial imaging to guide interventional radiologic therapy options.

Variant 8: Clinical suspicion of central venous stenosis or occlusion suggested by swelling (ie, soft tissue edema) of the extremity ipsilateral to the upper or lower extremity hemodialysis access, with or without the development of venous collaterals. Treatment and procedures.

Variant 9: Abnormal skin changes associated with the upper or lower extremity hemodialysis access cannulation site, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial or deep infection. Initial imaging to guide interventional radiologic therapy options.

Variant 10: Abnormal skin changes associated with the upper or lower extremity hemodialysis access cannulation site, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial or deep infection. Treatment and procedures.

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
A. Fluoroscopy Fistulography Hemodialysis Access Area of Interest

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
B. US Duplex Doppler Hemodialysis Access Area of Interest

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
C. CTA Extremity area of Interest With IV Contrast

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
D. CTV Extremity Area of Interest With IV Contrast

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
E. MRA Extremity Area of Interest Without and With IV Contrast

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
F. MRA Extremity Area of Interest Without IV Contrast

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
G. MRV Extremity Area of Interest Without and With IV Contrast

Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
H. MRV Extremity Area of Interest Without IV Contrast

Variant 12: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.

Variant 12: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.
A. Fluoroscopy Fistulography Hemodialysis Access with Intervention

Variant 12: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.
B. Surgical Consultation

Variant 12: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.
C. Placement of a New Tunneled Dialysis Catheter

Variant 12: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.
D. Continued Hemodialysis Access Use with Surveillance

Variant 12: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.
E. US Duplex Doppler Hemodialysis Access Area of Interest

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination