1047328 research-article2021 JVA0010.1177/11297298211047328The Journal of Vascular AccessIglesias et al. Original research article JVA The Journal of Vascular Access The Journal of Vascular Access Ultrasound guided cannulation 2021, Vol. 22(1S) 106­–112 © The Author(s) 2021 of dialysis access Article reuse guidelines: https://doi.org/10.1177/11297298211047328 sagepub.com/journals-permissions DOI: 10.1177/11297298211047328 journals.sagepub.com/home/jva Ruben Iglesias1 , Massimo Lodi2, Carolina Rubiella1, Maria Teresa Parisotto3 and Jose Ibeas1 Abstract Vascular access is the key part of haemodialysis (HD) treatment, as this is not possible without a functioning access. The use of the arteriovenous fistula (AVF) has fewer complications, lower mortality and fewer hospital admissions compared to central venous catheter (CVC). However, although guidelines recommend AVF as the access of choice, access-related cannulation complications may lead to greater morbidity. Most guidelines recommend using Doppler ultrasound (DU) to surveil the AVF for HD, but its use must not only be limited to surveillance as it can also be used for needling. Therefore, among those techniques at our disposal today, one of the best tools for AVF needling is Doppler ultrasound (DU). Despite the lack of evidence regarding ultrasound-guided needling of AVF, it is becoming part of our usual practice arsenal in many HD centres. Its use has allowed needling results to improve and the number of complications to be reduced versus traditional ‘blind’ needling. It should be remembered that even though it is very useful for the daily work of dialysis nurses, as in the case of other techniques, it requires adequate, specialised and long-term training to acquire competence in using it. For example, it is important to learn some concepts and terminology that should be known and, at the same time, be highly familiar with different techniques available. Two types of needling techniques are described using US assistance: US- guided needling, where DU is used to make a map of the vessels which can be utilised and to mark the best site to insert the needles once the mapping is done; and real-time US-guided needling, the simultaneous manipulation of the probe and the insertion of the puncture needle through the slice plane of the ultrasound device. Regarding the real-time technique, there are two approaches: out of plane (the probe takes a transversal image of the needle) and in plane (vessel axis aligned with the probe and the needle in the same plane) To ensure successful needling and to maximise reproducibility, especially with tight deadlines and staff resources, nursing staff need to follow some important recommendations that include safety and the use of the method, both for them and the patient. In this way, ultrasound-guided needling becomes a tool with enormous potential utility, but practical training is as important as knowing the technique. Keywords Cannulation, AV fistula, dialysis access, ultrasonography – Doppler evaluation, prosthetic grafts, techniques and procedures Date received: 24 May 2021; accepted: 1 September 2021. Vascular access (VA) is the key to effective haemodialy- 1  ephrology Department, Parc Taulí University Hospital, Parc Taulí N sis (HD), as without functioning access, treatment is not Research and Innovation Institute (I3PT), Autonomous University of possible. Vascular accesses for haemodialysis can be syn- Barcelona, Barcelona, Spain thesised in two large groups: arteriovenous fistulas (AVF) 2 Complex Operative Unit Nephrology and Dialysis and Simple and central venous catheters (CVC). At the same time, Operative Unit Interventional Nephrology, Spirito Santo Hospital, AVF can be native (nAVF) and prosthetic (pAVF). Fistula Pescara, Italy 3 European Specialist Nurses Organisation, Brussels, Belgium creation and maintenance have become more compli- cated in the last few years due to the increase in the age Corresponding author: of the patients initiating HD and to the consequent Ruben Iglesias, Department of Nephrology, Parc Taulí University Hospital, Parc Taulí Research and Innovation Institute (I3PT), increase in comorbidities, such as vascular as well as car- Autonomous University of Barcelona, Parc del Taulí 1, Sabadell, diac problems and diabetes, which have a well-known Barcelona 08208, Spain. negative effect on the state of the patient’s vascular tree. Email: riglesias1977@gmail.com Iglesias et al. 107 Table 1. Created Vs Usable Arteriovenous Fistula. Author Technique (physical examination vs USS or angiography, etc.) AVF creation rate (%) Percentage of usable AVF Allon et al.10 USS 34/64 16/34 Fullerton et al.9 USS + DOQI 23/39 79/71 Huber et al.8 USS + angiography 90 71 Patel et al.11 USS + angiography 61/73 73/57 The table indicates in the first column the name of the author and the year of publication of the articles8–11 the second column respectively indicates for each article the technique for preoperative mapping used; the third column indicates the percentage of fistulas made by comparing the methods used for pre-operative mapping; the fourth column indicates the percentage of usable fistulas compared to the percentage of fistulas made. It is evident in several articles how the percentage of fistulas that can be used does not correspond to the same percentage of fistulas made In addition, the haemodialysis population is progres- and its use is not recommended in clinical guidelines. sively changing. The last 2017 ERA EDTA Register These recommend rope-ladder as the technique of choice Census data shows how EU haemodialysis patients, over if there is a good vascular access with a good needling seg- the age of 65, comprise a total of 41% of patients with an ment. Regarding buttonhole technique, it is recommended incident percentage of 45%.1 for vascular accesses with specific characteristics (short The use of AVF, whether native or prosthetic and both in needling segment, presence of pathology that delimits the HD centres and home HD (HHD), has more favourable needling area, internal devices to guide needling, etc). associated results versus CVC use in terms of lower mortal- Furthermore, most guidelines recommend using Doppler ity, a lower percentage of technical failure in HHD cases and ultrasound (DU) to surveillance the VA for HD, but its use fewer hospital admissions.2–4 However, it is also known that in vascular access must not only be limited to surveillance these results may be limited by patient-related factors.5 but also to needling the access. There are studies showing that in the first 6 months of a Therefore, one of the best tools for AVF cannulation fistula’s life, there are many cannulation-related complica- among those at our disposal today is Doppler ultrasound tions, such as needling failures, use of catheters and hae- (DU).15 Despite the lack of evidence regarding ultrasound- modialysis with a single needle.6 guided needling of arteriovenous fistulae, DU is becoming In a recent publication, Pisoni et al.7 relying on the an usual practice in many HD centres. Its use has allowed study DOPPS data, has highlighted significant differences needling results to improve and the number of complica- between the native vascular access site and the success in tions to be reduced versus traditional ‘blind’ needling.16 its use in the DOPPS participating countries. However, in Some studies have been conducted on different cannula- Japan, there still remains a high percentage of native AVF tion techniques, such as those by Marticorena et al.,17 (91%) and distal sites (95%), whereas in Europe 69% are where needling is performed under US control by trained native AVF and 66% distal AVF, and in the United States, nurses in order to compare metallic versus plastic cannu- following the implementation of the Fistula First pro- lae. In another article, Marticorena et al.18 themselves gramme, 68% are native AVF, with a proximal AVF preva- describe the development of competencies that must be lence (68% vs 32% distal).7 acquired by nursing staff to use ultrasound to assess and Bearing in mind the numerous studies based on the cannulate the vascular access for HD. They describe three use of all the tools, native vascular access creation should levels of competence: basic, intermediate and advanced. be given maximum priority8–11 at the percentage of cre- Competences are acquired through theoretical and practi- ated AVF, but often is not the same percentage of usable cal sessions, as well as through training with simulation AVF (Table 1). All this leads to observe that AVF, often models before using it with patients. The authors comment very hard to create and difficult to use, would not reduce that people new to the use of this tool should be aware that the use of central venous catheters. it takes daily use of ultrasound at the patient’s bedside to However, although the guidelines12–14 recommend AVF acquire these competencies, and that around 500 ultra- as the access of choice, access-related cannulation compli- sound-guided needling’s are required to reach the maxi- cations may lead to greater morbidity.6 In many cases these mum competence described in the article. complications may lead to hospital admission, the need for Thanks to the expansion of the technique and its complementary examinations of the access and even to increasing use as a tool by nephrology nursing staff, pub- access loss. It must be remembered that when needling of lications have begun to appear dealing with cases in which the vascular access for HD is described, three techniques this technique has been used by nurses in complex fistu- to do it are detailed: area technique, rope ladder and but- lae.19 With reference to patient perception, one of the tonhole. The first of these, area technique, is the least rec- main reasons why the patient rejects the creation of a fis- ommended as it causes a greater number of complications tula is fear of cannulation failure, pain and the appearance 108 The Journal of Vascular Access 22(1S) Needling types with US assistance US-guided needling This is the use of ultrasound to make a map of the vessels which can be utilised by the access. Once the mapping has been done, the best site to insert the needles can be marked. In this technique, ultrasound is not really used during cannulation. To sum up, the steps taken in this technique are: Before proceeding with cannulation, it is necessary to: 1. Establish the vein segment; 2. Assess diameter, depth and flow (Figure 1); 3. Choose the site, marking it with a dermographic marker (Figure 2); 4. Choose the needling technique: rope ladder (pref- erably), or buttonhole technique. It is advisable to avoid area needling technique22–24; 5. For prosthetic AVF, it is mandatory to use the rope- ladder technique, as no strong scientific evidence supporting the use of buttonhole for this type of AVF has been generated yet. Real-time US-guided needling Real-time US-guided needling consists of the simultane- Figure 1. Diameter, depth and flow assessment. ous manipulation of the probe and the insertion of the puncture needle through the slice plane of the ultrasound device. The insertion is controlled in real-time, enabling the needle to be re-directed. One hand is used to insert the needle from one of the sides of the probe, while the other hand controls the needle trajectory with the probe. Both tools are handled with care to maintain the needle trajectory in the slice plane and direct it to the objective. This technique allows for greater freedom when choos- ing the entry path and enables the nurse to adjust the trajec- tory during cannulation. However, before beginning any procedure, it is essential to define and locate the vessel precisely. For this, the area where it is located must be carefully examined using ultrasound. The greatest difficulty that nurses encounter when put- ting this technique into practice is hand-eye coordination, therefore it is beneficial to create a visual map of the access anatomy. Figure 2. Site marking. Three elements must be interrelated when perform- ing real-time cannulation with ultrasound: the ultra- of haematoma.20 Other complications apart from haema- sound plane, the vein and the needle. The relationship toma, like multiple needling attempts, or extravasations, between the plane and the vessel can be transversal or increase patient dissatisfaction and evidently also increase longitudinal,15,16 while the relationship between plane treatment costs.21 and needle can be out of plane or in plane.25,26 The com- All the above mentioned can be improved or avoided bination of the plane-vein-needle relationship defines with the use of US. the approach. Iglesias et al. 109 Figure 3. Vessel placement (simulation model). Figure 5. Out of plane approach. ensure the widest area, just as in any circumference. The advantage of this view is that it allows cannula- tion in plane and gives a view of the needle throughout the segment. Relationship between the orientation of the probe with respect to the needle -Out of plane: the probe takes a transversal image of the needle, the vessel is circular as it is transversal to the Figure 4. Longitudinal image of the vessel (simulation model). probe (Figure 5), and the needle appears as a bright point. The main disadvantage is that it is not possible to determine exactly which segment of the needle is being Relationship between ultrasound plane and vein seen. Consequently, in order to locate the needle tip, a -Transversal or short axis: the beam of ultrasounds cuts series of search manoeuvres must be performed, such the vessel perpendicular to the long axis of the vessel, as the sliding manoeuvre and the inclination or tilting of thereby obtaining a circular section in the image. When the probe. a vessel is examined transversally, it must be placed in -In-plane: with the vessel axis aligned with the probe, the centre of the circular section of the vessel located in and the needle in the same plane (Figure 6), it is possi- the centre of the image (Figure 3). The main advantage ble to obtain a complete image of the needle, thereby of this plane is that allows a broad panoramic view of allowing the needle tip to be seen throughout its trajec- the vein and adjacent structures to be obtained. This tory as it progresses through the tissue. This kind of approach allows operators to avoid undesired needling approach is generally considered to be the approach of of risk structures like arteries and nerves. choice for US-guided techniques. -Longitudinal: the ultrasound beam cuts the vessels parallel to the long axis of the vessel, thereby obtain- Out of plane insertion technique. When the transversal out ing a longitudinal image of the vessel (Figure 4). of plane approach is used, the needling site in the skin can When a vessel is examined longitudinally, the plane be calculated with the triangulation principle (Figure 7). must be placed exactly in the middle of the vessel, to If an entry angle into the skin of 45° is used, the distance 110 The Journal of Vascular Access 22(1S) factor that is sometimes forgotten when inserting in plane is that the needle will be seen better if the ultrasound indices more tangentially on the needle. However, any randomised and controlled study can define the superiority of one of these approaches. So it seems correct to affirm that the best approach is the one the operator has more experience and is more familiar with. Recommendations First of all it should be remembered that even though ultra- sound guided cannulation is very useful for daily work of dialysis nurses, as other techniques requires adequate, spe- cialized and long time training to get the competences to use it.18 To ensure successful needling and to maximise repro- ducibility, especially with tight deadlines and staff resources, it is necessary to follow some important recom- mendations that include safety and the use of the method, both for the patient and nursing staff. 1. Make sure that: Figure 6. In plane approach. a. The patient feels comfortable and placed in a similar position to that of the haemodialysis session. between the probe and needle insertion point will be b. The operator feels comfortable with the bed at approximately the same as the depth at which the vessel the right height, the probe and its controls are is to be found.27 By using this simple principle, the vessel easily accessible and there will be sufficient can be needled successfully although the needle trajec- space and some adequate ambient lighting. tory cannot be controlled. The disadvantage is that if the 2. Identify the course and the depth of the vein. angle calculation and the depth are not exact, the ade- 3. Choose the skin entry site and orient the probe as quate trajectory of the needle can be wrong and undesired you prefer. structures can be needled. 4. Disinfect the cannulation area and put on the tourniquet. In plane insertion techniques. By using the longitudinal, 5. Use anaesthetic, if/where necessary. in-plane approach, the needle can be directly and contin- 6. Use a probe cover or clean the probe with sterile uously controlled but the operator must have extremely wipes. good manual skills. The most closely centred longitudi- 7. Put on a sterilised gel. nal plane of the vein is obtained in the vessel. The needle 8. Place the probe on the skin gently, avoiding is introduced laterally to the probe right next to the edge. unnecessary pressure, to not modify distances In this case there is no recommended distance for the between the probe, the skin and the vein. probe when needling, as this will vary depending on the 9. Make sure the probe is oriented correctly. longitude of the probe and the depth of the vessel. What 10. Insert the needle in the skin with a safe move- is fundamental is to keep it in the centre and keep the ment, possibly putting two fingers on the tube, hand holding the probe still while inserting the needle. close to the needle wings, to have more freedom The only hand that must be moved is the one holding the of movement. needle, which must be inserted into the skin in complete 11. Direct the probe to frame the needle perfectly and alignment with the centre of the probe. If the needle can- make sure you follow it during its trajectory in the not be seen during insertion, it is highly likely that the vein. probe or the needle insertion plane has been altered. In 12. If the needle is not perfectly framed, stop: do not this case, the needle must never be introduced further: it continue. Withdraw it progressively backwards must be withdrawn, and the plane and needle reposi- and re-direct the probe to frame it perfectly. This is tioned before reinserting the needle. A fundamental really important to avoid possible complications. Iglesias et al. 111 Figure 7. Triangulation principle. 13. Make sure the tip of the needle is in the middle of org/files/annualreports/AnnRep2017.pdf (accessed 14 July the vein. The blood in the tube will confirm it has 2021). been inserted correctly. 2. Ravani P, Palmer SC, Oliver MJ, et al. Associations between 14. Gently clean the gel from the skin, avoiding sud- hemodialysis access type and clinical outcomes: a system- atic review. J Am Soc Nephrol 2013; 24(3): 465–473. den movements that can move the needle and 3. Rivara MB, Soohoo M, Streja E, et al. Association of safely anchor it to the skin vascular access type with mortality, hospitalization, and transfer to in-center hemodialysis in patients undergoing Technology provides us with different tools to use with home hemodialysis. Clin J Am Soc Nephrol 2016; 11(2): ultrasound and in US-guided cannulation, including a port- 298–307. able probe as big as a smartphone which has a high-fre- 4. Perl J, Nessim SJ, Moist LM, et al. Vascular access type quency probe with excellent resolution and even a highly and patient and technique survival in home hemodialysis manageable wireless probe. patients: the Canadian organ replacement register. Am J Kidney Dis 2016; 67(2): 251–259. 5. Brown RS, Patibandla BK and Goldfarb-Rumyantzev AS. Acknowledgements The survival benefit of “fistula first, catheter last” in hemo- To Nuria Monill Raya, I3PT Biomedical Engineer for the col- dialysis is primarily due to patient factors. J Am Soc Nephrol laboration in the creation of the figures of the simulation of nee- 2017; 28(2): 645–652. dling approach. 6. Van Loon MM, Kessels AG, Van der Sande FM, et al. Cannulation and vascular access-related complications in Declaration of conflicting interests hemodialysis: factors determining successful cannulation. Hemodial Int 2009; 13: 498–504. The author(s) declared no potential conflicts of interest with 7. Pisoni RL, Zepel L, Fluck R, et al. International differences respect to the research, authorship, and/or publication of this in the location and use of arteriovenous accesses created for article. hemodialysis: results from the dialysis outcomes and prac- tice patterns study (DOPPS). Am J Kidney Dis 2018; 71(4): Funding 469–478. The author(s) received no financial support for the research, 8. Huber TS, Ozaki CK, Flynn TC, et al. Prospective valida- authorship, and/or publication of this article. tion of an algorithm to maximize native arteriovenous fis- tulae for chronic hemodialysis access. J Vasc Surg 2002; 36(3): 452–459. ORCID iDs 9. Fullerton JK, McLafferty RB, Ramsey DE, et al. Pitfalls Ruben Iglesias https://orcid.org/0000-0002-7202-4461 in achieving the dialysis outcome quality initiative (DOQI) Jose Ibeas https://orcid.org/0000-0002-1292-7271 guidelines for hemodialysis access. Ann Vasc Surg 2002; 16(5): 613–617. 10. Allon M, Lockhart ME, Lilly RZ, et al. Effect of preopera- References tive sonographic mapping on vascular access outcomes in 1. ERA-EDTA Registry. Annual report 2017, Amsterdam hemodialysis patients. Kidney Int 2001; 60(5): 2013–2020. UMC, location AMC, Department of Medical Informatics, 11. Patel ST, Hughes J and Mills JL Sr. Failure of arteriovenous Amsterdam, the Netherlands, 2019, https://era-edta-reg. fistula maturation: an unintended consequence of exceeding 112 The Journal of Vascular Access 22(1S) dialysis outcome quality initiative guidelines for hemodi- 19. Villanueva Bendek I, Ruiz M and Vega L. Use of ultrasound alysis access. J Vasc Surg 2003; 38(3): 439–445. for safe cannulation of difficult arteriovenous fistulas in 12. Lok CE, Huber TS, Lee T, et al. National Kidney Foundation. hemodialysis. Rev Colomb Nefrol 2019; 6(1): 48–56. KDOQI clinical practice guideline for vascular access: 2019 20. Xi W, Harwood L, Diamant MJ, et al. Patient attitudes update. Am J Kidney Dis 2020; Apr; 75(4 Suppl 2): S1–S164. towards the arteriovenous fistula: a qualitative study on 13. Gallieni M, Hollenbeck M, Inston N, et al. Clinical practice vascular access decision making. Nephrol Dial Transplant guideline on peri- and postoperative care of arteriovenous 2011; 26(10): 3302–3308. fistulas and grafts for haemodialysis in adults. Nephrol Dial 21. Lee T, Barker J and Allon M. Needle infiltration of arte- Transplant 2019; 34(Supplement_2): ii1–ii42. riovenous fistulae in hemodialysis: risk factors and conse- 14. Ibeas J, Roca-Tey R, Vallespín J, et al. Guía Clínica quences. Am J Kidney Dis 2006; 47(6): 1020–1026. Española del acceso vascular para hemodiálisis. Nefrologia 22. Kronung G. Plastic deformation of Cimino fistula by 2017; 37(Suppl 1): 1–191. repeated puncture. Nephrol Dial Transplant 1984; 13: 635. 15. Ward F, Faratro R and McQuillan RF. Ultrasound-Guided 23. Vachharajani TJ. The role of cannulation and fistula care. cannulation of the hemodialysis arteriovenous access. Semin Semin Dial 2015; 28(1): 24–27. Dial 2017; 30(4): 319–325. 24. Parisotto MT, Pelliccia F, Grassmann A, et al. Elements of 16. Patel RA, Stern AS, Brown M, et al. Bedside ultrasonogra- dialysis nursing practice associated with successful cannu- phy for arteriovenous fistula cannulation. Semin Dial 2015; lation: result of an international survey. J Vasc Access 2017; 28(4): 433–434. 18(2): 114–119. 17. Marticorena RM, Dacouris N and Donnelly SM. 25. AIUM practice parameter for the use of ultrasound to guide Randomized pilot study to compare metal needles versus vascular access procedures. J Ultrasound Med 2019; 38: plastic cannulae in the development of complications in E4–E18. hemodialysis access. J Vasc Access 2018; 19(3): 272–282. 26. Oulengo I, Ferrer A, Gil J, et al. Procedimientos ecoguiados. 18. Marticorena RM, Mills L, Sutherland K, et al. Development of SECIP 2018; 6: 1–12. competencies for the use of bedside ultrasound for assessment 27. Kamata T, Tomita M and Iehara N. Ultrasound-guided can- and cannulation of hemodialysis vascular access. CANNT J nulation of hemodialysis access. Ren Replace Therapy 2016; 2015; 25(4): 28–32. 2: 7.