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Paper |

Use of the Radial Artery for Hemodialysis Access FREE

Lawrence J. Goldstein, MD; Sandeep Gupta, BA
[+] Author Affiliations

From the Division of Vascular Surgery, Department of Surgery, University of California[[ndash]]San Francisco, East Bay, Oakland (Dr Goldstein); and Albert Einstein College of Medicine, Bronx, NY (Mr Gupta).


Arch Surg. 2003;138(10):1130-1134. doi:10.1001/archsurg.138.10.1130.
Text Size: A A A
Published online

Hypothesis  Under limited conditions, use of the radial artery (RA) for hemodialysis access in patients with end-stage renal disease is safe and effective.

Methods  The nondominant upper extremities of 211 consecutive patients with end-stage renal disease were evaluated with duplex ultrasonography to assess RA and ulnar artery (UA) flow contributions to their hands. Diameters and peak systolic velocities were measured in each artery, from which peak flows were calculated. Arteries of less than 2.0 mm in diameter were deemed unusable for access procedures or inadequate as the sole supply to the hand. Flow rates within 20% of each other were considered equivalent, and the RA was dominant if its flow exceeded that of the UA by 20%. Radial arteries with peak flow rates of less than 125 mL/min were judged inadequate, and RAs were not used in patients with peak UA flow rates of less than 100 mL/min.

Results  The RA flow was equivalent to the UA flow in 56 patients and was dominant in 120. Flow through the RA was adequate in 166 patients, but 41 had insufficient UA flow contributions and 15 had unsatisfactory UA diameters. Overall, 25 patients had inadequate RA diameters, 72 patients had inadequate UA diameters, and 16 patients had insufficient calibers of both vessels.

Conclusions  The RA carried sufficient flow to support a shunt or fistula in 78.7% of patients, but it would have been unwise to use it in about one third of those cases because of potentially insufficient perfusion to the hand by the UA. The RA could therefore be safely used in 49.8% of patients with end-stage renal disease evaluated for hemodialysis access.

Figures in this Article

THE RADIAL artery (RA) is considered by many to be expendable. This opinion probably stems from early reports that the ulnar artery (UA) is dominant in up to 90% of upper extremities115 and from anecdotal experience with RA lines and the use of the RA for hemodialysis access. Recent studies,1623 however, have shown that the RA carries as much flow to the hand as the UA and therefore may be more important than previously realized. Because almost all of these studies were carried out on normal volunteers, statements about arterial dominance in patients with renal failure cannot be made conclusively. This study was designed to give guidance as to when the RA can be safely used for hemodialysis access.

From January 6, 1997, to June 5, 2000, duplex ultrasonography of the RA, UA, and cephalic vein (CV) was performed on all patients with end-stage renal disease referred to the vascular surgery service for hemodialysis access. The nondominant upper extremities were evaluated, if possible. Radial artery, UA, and CV diameters and peak systolic velocities (PSVs) were measured. Peak arterial flows were calculated from the vessel diameter and PSV as the cross-sectional area multiplied by the PSV. Peak RA flows of less than 125 mL/min were deemed too low to support a straight shunt or an arteriovenous fistula. Peak UA flows of less than 100 mL/min were considered to be too low to be the sole contributor to the hand. Any artery of less than 2.0 mm in diameter was considered to be unusable or inadequate for hand perfusion by itself, and flows within 20% of each other were considered equivalent. An artery was considered dominant if it had 20% or greater flow than the comparative artery.

During the study, 211 patients were evaluated, 60.7% men and 39.3% women. The mean age was 49.8 years, and there was no statistically significant difference in age between men and women compared with the entire cohort (P = .64 and P = .72, respectively; 2-tailed t test). We studied the dominant upper extremity in 13 patients because they had central deep venous thromboses or all upper extremity vascular access sites had been used.

The causes of renal failure are shown in Table 1. Hypertension, seen in 84.8% of the study group, was the most common cause. Diabetes mellitus was found in 40.3%, and 34.1% had diabetes mellitus and hypertension. Less common causes were drug abuse (18.5%), glomerular nephritis (10.4%), and human immunodeficiency virus (HIV) in 5.7%. Fifteen percent (15.2%) of patients had other causes of renal failure, including systemic lupus erythematosus, polyarteritis nodosa, and obstructive uropathy. Many patients had multiple etiologies, and there was no significant etiologic difference between men and women by χ2 analysis (P = .78).

Table Graphic Jump LocationTable 1. Causes of Renal Failure in 211 Patients Being Evaluated for Hemodialysis Access

The mean RA peak flow was 252 mL/min, and the mean UA peak flow was 173 mL/min (P<.001, 2-tailed t test). The mean RA diameter was 2.74 mm, and the mean UA was 2.24 mm (P<.001, 2-tailed t test). The mean CV diameter was 2.43 mm.

The RA was found to be dominant in 56.9% of our patients. Stratifying the population into right- and left-handed patients, the RA was dominant in 56.3% and 64.3%, respectively. In the 13 patients who had their dominant extremity studied, the RA was dominant in 69.2%. There were no statistically significant differences between men and women and right- and left-handedness (χ2 = 0.008, P = .93).

The RA and UA carried equal (within 20%) contributions in 26.5% of individuals. There was no significant difference in this distribution by sex (χ2 = 0.02, P = .90). The RA exceeded or equaled the UA flow in 83.4% of patients. Stratification by handedness revealed that 83.8% of right-handed patients and 78.6% of left-handed patients had dominant RAs or RA flow that was equivalent to that of the UA (Table 2).

Table Graphic Jump LocationTable 2. Number of Patients With Radial Artery Flow Greater Than or Equal to Ulnar Artery Flow

Nearly 79% (78.7%) of our patients had peak RA flow of 125 mL/min, but only 59.2% also had peak UA flow of at least 100 mL/min. Only 49.8% of our patients also had both arteries at least 2.0 mm in diameter in addition to peak RA flow of 125 mL/min. A total of 186 patients had RAs larger than 2.0 mm, 139 had UAs greater than 2.0 mm, and 195 had both their RA and UA greater than 2.0 mm. Making the flow and diameter requirements more stringent, 71.1% of the patients could supply peak RA flow to at least 150 mL/min, but this fell to 48.3% when the minimum peak UA flow was set to 120 mL/min, and to 28.0% when requiring both arteries to be at least 2.5 mm (Table 3).

Table Graphic Jump LocationTable 3. Number of Patients With Sufficient Radial Artery (RA) and Ulnar Artery (UA) Flow to Support the Safe Use of the RA for Hemodialysis*

Forty-five percent of patients had CV diameters of greater than 2.5 mm, and 29.9% had CV diameters of greater than 3.0 mm. Almost 25% (24.6%) of our patients had a CV of 3.0 mm and peak RA flow of at least 125 mL/min. This diminished to 20.9% when requiring peak UA flow of 100 mL/min and arterial diameters of at least 2.0 mm. Requiring the peak RA flow to be 150 mL/min with a CV of 3.0 mm or greater identified only 18.0% of all the patients, and this fell to 13.7% when requiring peak UA flow of 120 mL/min and arterial diameters of at least 2.5 mm (Table 4).

Table Graphic Jump LocationTable 4. Number of Patients Who Are Candidates for Use of the RA for Cimino Fistulae*

The RA can serve as a conduit for hemodialysis access in 2 ways: as inflow for a straight shunt or for an autogenous fistula. Considering peak RA flow of 125 mL/min as an acceptable lower limit—because we expect the flow through the RA to achieve at least 200 mL/min as the shunt matures24 (the practical lower limit for hemodialysis)—then 78.7% of our patients had eligible RAs. But this percentage is obtainable only if there is no concern about perfusion to the hand after the operation, especially should the RA be obliterated because of complications after the operation.2559 With this in mind, adding the requirement that the RA and UA must be at least 2.0 mm in diameter and that the UA must carry at least 100 mL/min peak flow, only 49.8% of the study group could have had their RAs used, which coincides with the percentage that the National Kidney Foundation's Dialysis Outcome Quality Initiative guidelines suggest.6068

Making the requirements for peak RA and UA flows more stringent at 150 and 120 mL/min, respectively, with minimum RA and UA diameters of 2.5 mm resulted in 28.0% of patients being eligible to have their RAs used for hemodialysis access. This low rate suggests that, although these requirements appear reasonable, they may be excessive. Perhaps the UA remodels to augment flow after shunting flow away from the RA, or the interosseous arteries are more participatory than expected in perfusing the hand, making a low preoperative flow measurement in the UA less important than it would appear. This concept was not investigated in this study, but evaluating the flow contributions to the hand by the RA and UA after a shunt has been implanted might settle this issue.48

One may question why PSV was chosen as a reflection of flow in the vessel when it is roughly 3 times the actual flow in that vessel.69 The reason is that we wanted an estimation of the maximal flow the vessel could supply after the shunt or fistula was placed. The peak flow in the RA is probably the best estimation of the maximal obtainable flow in it immediately after the operation. In time, the artery and vein are expected to dilate and achieve even greater flows than the PSV would have suggested by virtue of accommodation to higher flow rates.

Before using the RA for inflow into a Cimino fistula, CV patency and diameter must be ascertained. It is doubtful that any CV of less than 2.5 mm will mature sufficiently for use. Forty-five percent of our patients were eligible for Cimino fistulae based on having a CV diameter of at least 2.5 mm alone. Many surgeons prefer a larger CV before attempting a Cimino fistula. Increasing the CV diameter requirement to 3.0 mm resulted in only 29.9% of our patients being candidates. In addition to the size of the CV, the peak flow and diameter of the RA and UA must be able to support the fistula. Nearly 25% (24.6%) of our patients had peak RA flows of greater than 125 mL/min and 3.0-mm-diameter CVs. Requiring that the UA carry at least 100 mL/min peak flow and that both arteries be at least 2.0 mm in diameter resulted in a loss of 8 patients, diminishing the pool of candidates for Cimino fistulae to 20.9%. Had the more stringent criteria of peak RA flow of 150 mL/min, UA flow of 120 mL/min, and RA and UA diameters of 2.5 mm been used, only 13.7% of our patients would have been candidates for Cimino fistulae. This is far below the guidelines of the National Kidney Foundation's Dialysis Outcome Quality Initiative consensus statement,6068 despite a high percentage of available RAs for Cimino fistulae. This was largely due to inadequate CVs in our population.

The RA carried as much or more flow than the UA in 83.4% of our patients. Clinical experience tells us that hand perfusion is uncommonly impaired, despite the use of the RA for arterial lines, blood gases, ligation in trauma, arterial conduits, free flaps, and hemodialysis access.2535 Even if the RA thromboses from RA manipulation, numerous authors have suggested that it may recanalize.15,29,70 What, then, is the clinical significance of this high percentage of RA dominance or equivalence? Studying wrist anatomy yields some possible answers (Figure 1).37 The hand is supplied by the RA, UA, and 2 interosseous arteries. The RA trifurcates at the wrist. Anteriorly, the RA bifurcates into superficial and deep branches that supply the superficial and deep palmar arches, which anastomose to the UA. Posteriorly, the RA sends off a dorsal carpal branch, which forms the dorsal carpal arch. The anterior and posterior interosseous arteries, like the peroneal artery in the lower extremity, give off branches to the RA and UA in the wrist. If the RA is obliterated at the deep branch, it may have no effect because of collateral perfusion by 1 or both of the other RA branches. Obliterating the RA more proximally at the trifurcation, on the other hand, may have a profound effect if the UA or interosseous arteries or both are insufficient. Even if the UA or interosseous arteries are impaired, loss of RA flow may precipitate remodeling of the remaining vessels and avert ischemia. Alternatively, any 1 of the 3 RA branches may recanalize, or the RA connection to the interosseous arteries may help supply the hand. Still, it would be prudent to rule out the use of the RA in "obvious" cases in which the RA is strongly dominant and collateral perfusion is minimal or nonexistent, which this study suggests occurs more commonly than previously believed.

Place holder to copy figure label and caption

Vascular anatomy of the perfusion to the hand. Reprinted with permission from Uflacker R, ed. Atlas of Vascular Anatomy: An Angiographic Approach. Baltimore, Md: Williams & Wilkins; 1996:379 (figure 15.28).

Graphic Jump Location

The RA carried sufficient flow to support a fistula or shunt 78.7% of the time, but it would have been unwise to use it in about a third of those cases because of potentially insufficient perfusion to the hand by the UA should the RA be obliterated. The RA could therefore be safely used in 49.8% of our patients with end-stage renal disease being evaluated for hemodialysis access. Because the CV was occluded or too small in most cases, only 20.9% of our patients were candidates for a Cimino fistula.

Corresponding author and reprints: Lawrence J. Goldstein, MD, Division of Vascular Surgery, Department of Surgery, University of California–San Francisco, East Bay, 1411 E 31st St, Oakland, CA 94602 (e-mail: GoldsteinL@surgery.ucsf.edu).

Accepted for publication April 27, 2003.

This study was presented at the 6th Annual Indiana University Hemodialysis and Venous Intervention Symposium; March 2, 2002; Keystone, Colo. It was also presented in part as a poster at the 74th Annual Meeting of the Pacific Coast Surgical Association; February 18, 2003; Monterey, Calif.

Brodsky  JB A simple method to determine patency of the ulnar artery intraoperatively prior to radial-artery cannulation. Anesthesiology. 1975;42626- 627
PubMed
Ballard  JLSmith  LL Surgical anatomy for vascular access procedures. Vasc Access. 2002;319- 28
Mozersky  DJBuckley  CJHagood Jr  COCapps Jr  WFDannemiller Jr  FJ Ultrasonic evaluation of the palmar cannulation: a useful adjunct to radial artery cannulation. Am J Surg. 1973;126810- 812
PubMed
Doscher  WViswanathan  BStein  TMargolis  IB Hemodynamic assessment of the circulation in 200 normal hands. Ann Surg. 1983;198776- 779
PubMed
Mandel  MADauchnot  PJ Radial artery cannulation in 1000 patients: precautions and complications. J Hand Surg Am. 1977;2482- 485
PubMed
Palm  T Evaluation of peripheral arterial pressure on the thumb following radial artery cannulation. Br J Anaesth. 1977;49819- 824
PubMed
Davis  FM Radial artery cannulation: influence of catheter size and material on arterial occlusion. Anaesth Intensive Care. 1978;649- 53
PubMed
Bedford  RF Radial arterial function following percutaneous cannulation with 18- and 20-gauge catheters. Anesthesiology. 1977;4737- 39
PubMed
Slogoff  SKeats  ASArlund  C On the safety of radial artery cannulation. Anesthesiology. 1983;5942- 47
PubMed
Scavenius  MFauner  MWalther-Larsen  SBuchwald  CNielsen  SL A quantitative Allen's test. Hand. 1981;13318- 320
PubMed
Husum  BBerthelsen  P Allen's test and systolic arterial pressure in the thumb. Br J Anaesth. 1981;53635- 637
PubMed
Dahl  MRSmead  WLMcSweeney  TD Radial artery cannulation: a comparison of 15.2- and 4.45-cm catheters. J Clin Monit. 1992;8193- 197
PubMed
Johnson  MFord  MJohansen  K Radial or ulnar artery laceration: repair or ligate? Arch Surg. 1993;128971- 974
PubMed
Galli  MZerboni  SPoliti  APaone  RFerrari  G Transradial approach for coronary procedures: initial experience and results. G Ital Cardiol. 1998;28767- 773
PubMed
Stella  PRKiemeneij  FLaarman  GJOdekerken  DSlagboom  Tvan der Wieken  R Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn. 1997;40156- 158
PubMed
Husum  BPalm  T Arterial dominance in the hand. Br J Anaesth. 1978;50913- 916
PubMed
Dumanian  GASegalman  KBuehner  JWKoontz  CLHendrickson  MFWilgis  EF Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg. 1998;1021993- 1998
PubMed
Kleinert  JMFleming  SGAbel  CSFirrell  J Radial and ulnar artery dominance in normal digits. J Hand Surg Am. 1989;14504- 508
PubMed
Tonks  AMLawrence  JLovie  MJ Comparison of ulnar and radial arterial blood-flow at the wrist. J Hand Surg Br. 1995;20240- 242
PubMed
Dost  PRudofsky  G Doppler ultrasonography as a pre-operative aid to base the forearm flap on the radial or ulnar artery. Clin Otolaryngol. 1993;18355- 358
PubMed
Fuhrman  TMReilley  TEPippin  WD Comparison of digital blood pressure, plethysmography, and the modified Allen's test as means of evaluating the collateral circulation to the hand. Anaesthesia. 1992;47959- 961
PubMed
Patsalis  THiffmeister  BESeboldt  H Arterial dominance of the hand. Handchir Mikrochir Plast Chir. 1997;29247- 250
PubMed
Benit  EVranckx  PJaspers  LJackmaert  RPoelmans  CConinx  R Frequency of a positive modified Allen's test in 1,000 consecutive patients undergoing cardiac catheterization. Cathet Cardiovasc Diagn. 1996;38352- 354
PubMed
Shemesh  DMabjeesh  NJAbramowitz  HB Management of dialysis access–associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction. J Vasc Surg. 1999;30193- 195
PubMed
Starnes  SLWolk  SWLampman  RM  et al.  Noninvasive evaluation of hand circulation before radial artery harvest for coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1999;117261- 266
PubMed
Royse  AGRoyse  CFShah  PWilliams  AKaushik  STatoulis  J Radial artery harvest technique, use and functional outcome. Eur J Cardiothorac Surg. 1999;15186- 193
PubMed
Fox  ADWhitley  MSPhillips-Hughes  JRoarke  J Acute upper limb ischemia: a complication of coronary artery bypass grafting. Ann Thorac Surg. 1999;67535- 536
PubMed
Nie  MOhara  KMiyoshi  YTsukuda  KTorii  SYoshimura  H Ulnar artery graft for myocardial revascularization. Jpn J Thorac Cardiovasc Surg. 2000;48112- 114
PubMed
Wilkins  RG Radial artery cannulation and ischemic damage: a review. Anaesthesia. 1985;40896- 899
PubMed
Jones  BMO'Brien  CJ Acute ischemia of the hand resulting from evaluation of a radial forearm flap. Br J Plast Surg. 1985;38396- 397
PubMed
Matthews  RNFatah  FDavies  DMEyre  JHodge  RAWalsh-Waring  GP Experience with the radial forearm flap in 14 cases. Scand J Plast Reconstr Surg. 1984;18303- 310
PubMed
Campkin  TV Radial artery cannulation: potential hazard in patients with acromegaly. Anaesthesia. 1980;351008- 1009
PubMed
Johnson III  WHCromartie III  RSArrants  JEWuamett  JDHolt  JB Simplified method for candidate selection for radial artery harvesting. Ann Thorac Surg. 1998;651167
PubMed
Guillard  NLefevre  TSpaulding  C  et al.  Coronary angiography by left radial approach: a bi-center prospective pilot study [in French]. Arch Mal Coeur Vaiss. 1997;901349- 1355
PubMed
Aronson  SAlbertucci  M Assessing flow during minimally invasive coronary artery bypass: an Allen's test equivalent. Ann Thorac Surg. 1999;671173- 1174
PubMed
Janeveski  B Arteries of the hand in patients with scleroderma. Diagn Imaging Clin Med. 1986;55262- 265
PubMed
Gelberman  RHPanagis  JSTaleisnik  JBaumgaertner  M The arterial anatomy of the human carpus, I: the extraosseous vascularity. J Hand Surg Am. 1983;8367- 375
PubMed
Ruch  DSAldridge  MHolden  MSmith  TLKoman  LASmith  BP Arterial reconstruction for radial artery occlusion. J Hand Surg Am. 2000;25282- 290
PubMed
Gouet  OHautefort  EIselin  F Acute ischemia of the fingers. Ann Chir Main. 1989;8352- 355
PubMed
Bellan  NVongsouthi  SDauzat  MGomis  RAllieu  Y Post-operative Doppler evaluation of 48 arterial reconstructions at the wrist. Ann Chir Main. 1989;822- 29
PubMed
Pistorius  MAPlanchon  B Diagnostic importance of digital topographic assessment of Raynaud's phenomenon: a prospective study of a population of 522 patients [in French]. J Mal Vasc. 1995;2014- 20
PubMed
Pistorius  MAde Faucal  PPlanchon  BGrolleau  JY Importance of the Allen test in the diagnosis of distal arteriopathy in Raynaud's phenomenon: prospective study on a continuous series of 576 patients. J Mal Vasc. 1994;1917- 21
PubMed
Stafford  LEnglert  HGover  JBertouch  J Distribution of macrovascular disease in scleroderma. Ann Rheum Dis. 1998;57476- 479
PubMed
Fronek  AKing  D An objective sequential compression test to evaluate the patency of the radial and ulnar arteries. J Vasc Surg. 1985;2450- 452
PubMed
O'Mara  KSullivan  B A simple bedside test to identify ulnar collateral flow [letter]. Ann Intern Med. 1995;123637
PubMed
Fuhrman  TMMcSweeney  E Noninvasive evaluation of the collateral circulation of the hand. Acad Emerg Med. 1995;2195- 199
PubMed
Trager  SPignataro  MAnderson  JKleinert  JM Color flow Doppler: imaging the upper extremity. J Hand Surg Am. 1993;18621- 625
PubMed
Rutherford  RB The value of noninvasive testing before and after hemodialysis access in the prevention and management of complications. Semin Vasc Surg. 1997;10157- 161
PubMed
Tordoir  JHHoeneveld  HEikelboom  BCKitslaar  PJ The correlation between clinical and duplex ultrasound parameters and the development of complications in arterio-venous fistulae for haemodialysis. Eur J Vasc Surg. 1990;4179- 184
PubMed
Cable  DGMullany  CJSchaff  HV The Allen test. Ann Thorac Surg. 1999;67876- 877
PubMed
Koman  LA Current status of noninvasive techniques in the diagnosis of upper extremity disorders, I: evaluation of vascular competency. Instr Course Lect. 1983;3261- 76
PubMed
Stead  SWStirt  JA Assessment of digital blood flow and palmar collateral circulation: Allen's test vs photophlethysmography. Int J Clin Monit Comput. 1985;229- 34
PubMed
Marcillon  MMaestracci  PGuillot  FDulbecco  PFilippi  CValici  A Doppler velocimetric evaluation of the reliability of Allen's test for radial artery catheterization [in French]. Ann Fr Anesth Reanim. 1982;1403- 406
PubMed
Cheng  EYLauer  KKStommel  KAGuenther  NR Evaluation of the palmer circulation by pulse oximetry. J Clin Monit. 1989;51- 3
PubMed
Ruland  OBorkenhagen  NPrien  T The Doppler palm test [in German]. Ultraschall Med. 1988;963- 66
PubMed
Tian  GL Clinical evaluation of blood supply of the hand [in Chinese]. Zhonghua Wai Ke Za Zhi. 1992;30534- 571
Levinsohn  DGGordon  LSessler  DI The Allen's test: analysis of four methods. J Hand Surg Am. 1991;16279- 282
PubMed
Mercier  FJBasdevant  CDe Tovar  GFischler  M Doppler preoperative evaluation of the prevalence of functional abnormalities of palmer arches in children. Ann Fr Anesth Reanim. 1994;13785- 788
PubMed
Vu-Rose  TEbramzadeh  ELane  CSKuschner  SH The Allen test: a study of inter-observer reliability. Bull Hosp Jt Dis. 1997;5699- 101
PubMed
Ascher  EGade  PHingorani  A  et al.  Changes in the practice of angioaccess surgery: impact of dialysis outcome and quality initiative recommendations. J Vasc Surg. 2000;31 (1pt 1) 84- 92
PubMed
Eknoyan  GLevin  NWEschbach  JW  et al.  Continuous quality improvement: DOQI becomes K/DOQI and is updated: National Kidney Foundation's Dialysis Outcomes Quality Initiative. Am J Kidney Dis. 2001;37179- 194
PubMed
Spergel  LM DOQI guidelines and the vascular access puzzle: finding the pieces that fit. Nephrol News Issues. 1998;1246- 50
PubMed
Not Available, DOQI guidelines, IV: adequacy, HD dose, reuse, compliance. Nephrol News Issues. 1997;1152- 53
PubMed
Glazer  SCrooks  PShapiro  MDiesto  J Using CQI and the DOQI guidelines to improve vascular access outcomes: the Southern California Kaiser Permanente experience. Nephrol News Issues. 2000;1421- 27
PubMed
National Kidney Foundation, NKF-DOQI clinical practice guidelines for vascular access. Am J Kidney Dis. 1997;30 (4 suppl 3) S150- S191
Not Available, I: NKF-K/DOQI clinical practice guidelines for hemodialysis adequacy: update 2000. Am J Kidney Dis. 2001;37 (1 suppl 1) S7- S64
PubMed
National Kidney Foundation, NKF-DOQI clinical practice guidelines for hemodialysis adequacy. Am J Kidney Dis. 1997;30 (3 suppl 2) S15- S66
Not Available, NKF-DOQI clinical practice guidelines for the treatment of anemia of chronic renal failure: National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis. 1997;30 (4 suppl 3) S192- S240
Gravenstein  NGood  MLBanner  TE Assessment of cardiopulmonary function. Civetta  JMTaylor  RWKirby  RRCritical Care 3rd ed. Philadelphia, Pa Lippincott-Raven Publishers1997;867- 898
Cederholm  LSorenson  JCarlsson  C Thrombosis following percutaneous radial artery cannulation. Acta Anaesthesiol Scand. 1986;30227- 230
PubMed

Figures

Place holder to copy figure label and caption

Vascular anatomy of the perfusion to the hand. Reprinted with permission from Uflacker R, ed. Atlas of Vascular Anatomy: An Angiographic Approach. Baltimore, Md: Williams & Wilkins; 1996:379 (figure 15.28).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Causes of Renal Failure in 211 Patients Being Evaluated for Hemodialysis Access
Table Graphic Jump LocationTable 2. Number of Patients With Radial Artery Flow Greater Than or Equal to Ulnar Artery Flow
Table Graphic Jump LocationTable 3. Number of Patients With Sufficient Radial Artery (RA) and Ulnar Artery (UA) Flow to Support the Safe Use of the RA for Hemodialysis*
Table Graphic Jump LocationTable 4. Number of Patients Who Are Candidates for Use of the RA for Cimino Fistulae*

References

Brodsky  JB A simple method to determine patency of the ulnar artery intraoperatively prior to radial-artery cannulation. Anesthesiology. 1975;42626- 627
PubMed
Ballard  JLSmith  LL Surgical anatomy for vascular access procedures. Vasc Access. 2002;319- 28
Mozersky  DJBuckley  CJHagood Jr  COCapps Jr  WFDannemiller Jr  FJ Ultrasonic evaluation of the palmar cannulation: a useful adjunct to radial artery cannulation. Am J Surg. 1973;126810- 812
PubMed
Doscher  WViswanathan  BStein  TMargolis  IB Hemodynamic assessment of the circulation in 200 normal hands. Ann Surg. 1983;198776- 779
PubMed
Mandel  MADauchnot  PJ Radial artery cannulation in 1000 patients: precautions and complications. J Hand Surg Am. 1977;2482- 485
PubMed
Palm  T Evaluation of peripheral arterial pressure on the thumb following radial artery cannulation. Br J Anaesth. 1977;49819- 824
PubMed
Davis  FM Radial artery cannulation: influence of catheter size and material on arterial occlusion. Anaesth Intensive Care. 1978;649- 53
PubMed
Bedford  RF Radial arterial function following percutaneous cannulation with 18- and 20-gauge catheters. Anesthesiology. 1977;4737- 39
PubMed
Slogoff  SKeats  ASArlund  C On the safety of radial artery cannulation. Anesthesiology. 1983;5942- 47
PubMed
Scavenius  MFauner  MWalther-Larsen  SBuchwald  CNielsen  SL A quantitative Allen's test. Hand. 1981;13318- 320
PubMed
Husum  BBerthelsen  P Allen's test and systolic arterial pressure in the thumb. Br J Anaesth. 1981;53635- 637
PubMed
Dahl  MRSmead  WLMcSweeney  TD Radial artery cannulation: a comparison of 15.2- and 4.45-cm catheters. J Clin Monit. 1992;8193- 197
PubMed
Johnson  MFord  MJohansen  K Radial or ulnar artery laceration: repair or ligate? Arch Surg. 1993;128971- 974
PubMed
Galli  MZerboni  SPoliti  APaone  RFerrari  G Transradial approach for coronary procedures: initial experience and results. G Ital Cardiol. 1998;28767- 773
PubMed
Stella  PRKiemeneij  FLaarman  GJOdekerken  DSlagboom  Tvan der Wieken  R Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn. 1997;40156- 158
PubMed
Husum  BPalm  T Arterial dominance in the hand. Br J Anaesth. 1978;50913- 916
PubMed
Dumanian  GASegalman  KBuehner  JWKoontz  CLHendrickson  MFWilgis  EF Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg. 1998;1021993- 1998
PubMed
Kleinert  JMFleming  SGAbel  CSFirrell  J Radial and ulnar artery dominance in normal digits. J Hand Surg Am. 1989;14504- 508
PubMed
Tonks  AMLawrence  JLovie  MJ Comparison of ulnar and radial arterial blood-flow at the wrist. J Hand Surg Br. 1995;20240- 242
PubMed
Dost  PRudofsky  G Doppler ultrasonography as a pre-operative aid to base the forearm flap on the radial or ulnar artery. Clin Otolaryngol. 1993;18355- 358
PubMed
Fuhrman  TMReilley  TEPippin  WD Comparison of digital blood pressure, plethysmography, and the modified Allen's test as means of evaluating the collateral circulation to the hand. Anaesthesia. 1992;47959- 961
PubMed
Patsalis  THiffmeister  BESeboldt  H Arterial dominance of the hand. Handchir Mikrochir Plast Chir. 1997;29247- 250
PubMed
Benit  EVranckx  PJaspers  LJackmaert  RPoelmans  CConinx  R Frequency of a positive modified Allen's test in 1,000 consecutive patients undergoing cardiac catheterization. Cathet Cardiovasc Diagn. 1996;38352- 354
PubMed
Shemesh  DMabjeesh  NJAbramowitz  HB Management of dialysis access–associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction. J Vasc Surg. 1999;30193- 195
PubMed
Starnes  SLWolk  SWLampman  RM  et al.  Noninvasive evaluation of hand circulation before radial artery harvest for coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1999;117261- 266
PubMed
Royse  AGRoyse  CFShah  PWilliams  AKaushik  STatoulis  J Radial artery harvest technique, use and functional outcome. Eur J Cardiothorac Surg. 1999;15186- 193
PubMed
Fox  ADWhitley  MSPhillips-Hughes  JRoarke  J Acute upper limb ischemia: a complication of coronary artery bypass grafting. Ann Thorac Surg. 1999;67535- 536
PubMed
Nie  MOhara  KMiyoshi  YTsukuda  KTorii  SYoshimura  H Ulnar artery graft for myocardial revascularization. Jpn J Thorac Cardiovasc Surg. 2000;48112- 114
PubMed
Wilkins  RG Radial artery cannulation and ischemic damage: a review. Anaesthesia. 1985;40896- 899
PubMed
Jones  BMO'Brien  CJ Acute ischemia of the hand resulting from evaluation of a radial forearm flap. Br J Plast Surg. 1985;38396- 397
PubMed
Matthews  RNFatah  FDavies  DMEyre  JHodge  RAWalsh-Waring  GP Experience with the radial forearm flap in 14 cases. Scand J Plast Reconstr Surg. 1984;18303- 310
PubMed
Campkin  TV Radial artery cannulation: potential hazard in patients with acromegaly. Anaesthesia. 1980;351008- 1009
PubMed
Johnson III  WHCromartie III  RSArrants  JEWuamett  JDHolt  JB Simplified method for candidate selection for radial artery harvesting. Ann Thorac Surg. 1998;651167
PubMed
Guillard  NLefevre  TSpaulding  C  et al.  Coronary angiography by left radial approach: a bi-center prospective pilot study [in French]. Arch Mal Coeur Vaiss. 1997;901349- 1355
PubMed
Aronson  SAlbertucci  M Assessing flow during minimally invasive coronary artery bypass: an Allen's test equivalent. Ann Thorac Surg. 1999;671173- 1174
PubMed
Janeveski  B Arteries of the hand in patients with scleroderma. Diagn Imaging Clin Med. 1986;55262- 265
PubMed
Gelberman  RHPanagis  JSTaleisnik  JBaumgaertner  M The arterial anatomy of the human carpus, I: the extraosseous vascularity. J Hand Surg Am. 1983;8367- 375
PubMed
Ruch  DSAldridge  MHolden  MSmith  TLKoman  LASmith  BP Arterial reconstruction for radial artery occlusion. J Hand Surg Am. 2000;25282- 290
PubMed
Gouet  OHautefort  EIselin  F Acute ischemia of the fingers. Ann Chir Main. 1989;8352- 355
PubMed
Bellan  NVongsouthi  SDauzat  MGomis  RAllieu  Y Post-operative Doppler evaluation of 48 arterial reconstructions at the wrist. Ann Chir Main. 1989;822- 29
PubMed
Pistorius  MAPlanchon  B Diagnostic importance of digital topographic assessment of Raynaud's phenomenon: a prospective study of a population of 522 patients [in French]. J Mal Vasc. 1995;2014- 20
PubMed
Pistorius  MAde Faucal  PPlanchon  BGrolleau  JY Importance of the Allen test in the diagnosis of distal arteriopathy in Raynaud's phenomenon: prospective study on a continuous series of 576 patients. J Mal Vasc. 1994;1917- 21
PubMed
Stafford  LEnglert  HGover  JBertouch  J Distribution of macrovascular disease in scleroderma. Ann Rheum Dis. 1998;57476- 479
PubMed
Fronek  AKing  D An objective sequential compression test to evaluate the patency of the radial and ulnar arteries. J Vasc Surg. 1985;2450- 452
PubMed
O'Mara  KSullivan  B A simple bedside test to identify ulnar collateral flow [letter]. Ann Intern Med. 1995;123637
PubMed
Fuhrman  TMMcSweeney  E Noninvasive evaluation of the collateral circulation of the hand. Acad Emerg Med. 1995;2195- 199
PubMed
Trager  SPignataro  MAnderson  JKleinert  JM Color flow Doppler: imaging the upper extremity. J Hand Surg Am. 1993;18621- 625
PubMed
Rutherford  RB The value of noninvasive testing before and after hemodialysis access in the prevention and management of complications. Semin Vasc Surg. 1997;10157- 161
PubMed
Tordoir  JHHoeneveld  HEikelboom  BCKitslaar  PJ The correlation between clinical and duplex ultrasound parameters and the development of complications in arterio-venous fistulae for haemodialysis. Eur J Vasc Surg. 1990;4179- 184
PubMed
Cable  DGMullany  CJSchaff  HV The Allen test. Ann Thorac Surg. 1999;67876- 877
PubMed
Koman  LA Current status of noninvasive techniques in the diagnosis of upper extremity disorders, I: evaluation of vascular competency. Instr Course Lect. 1983;3261- 76
PubMed
Stead  SWStirt  JA Assessment of digital blood flow and palmar collateral circulation: Allen's test vs photophlethysmography. Int J Clin Monit Comput. 1985;229- 34
PubMed
Marcillon  MMaestracci  PGuillot  FDulbecco  PFilippi  CValici  A Doppler velocimetric evaluation of the reliability of Allen's test for radial artery catheterization [in French]. Ann Fr Anesth Reanim. 1982;1403- 406
PubMed
Cheng  EYLauer  KKStommel  KAGuenther  NR Evaluation of the palmer circulation by pulse oximetry. J Clin Monit. 1989;51- 3
PubMed
Ruland  OBorkenhagen  NPrien  T The Doppler palm test [in German]. Ultraschall Med. 1988;963- 66
PubMed
Tian  GL Clinical evaluation of blood supply of the hand [in Chinese]. Zhonghua Wai Ke Za Zhi. 1992;30534- 571
Levinsohn  DGGordon  LSessler  DI The Allen's test: analysis of four methods. J Hand Surg Am. 1991;16279- 282
PubMed
Mercier  FJBasdevant  CDe Tovar  GFischler  M Doppler preoperative evaluation of the prevalence of functional abnormalities of palmer arches in children. Ann Fr Anesth Reanim. 1994;13785- 788
PubMed
Vu-Rose  TEbramzadeh  ELane  CSKuschner  SH The Allen test: a study of inter-observer reliability. Bull Hosp Jt Dis. 1997;5699- 101
PubMed
Ascher  EGade  PHingorani  A  et al.  Changes in the practice of angioaccess surgery: impact of dialysis outcome and quality initiative recommendations. J Vasc Surg. 2000;31 (1pt 1) 84- 92
PubMed
Eknoyan  GLevin  NWEschbach  JW  et al.  Continuous quality improvement: DOQI becomes K/DOQI and is updated: National Kidney Foundation's Dialysis Outcomes Quality Initiative. Am J Kidney Dis. 2001;37179- 194
PubMed
Spergel  LM DOQI guidelines and the vascular access puzzle: finding the pieces that fit. Nephrol News Issues. 1998;1246- 50
PubMed
Not Available, DOQI guidelines, IV: adequacy, HD dose, reuse, compliance. Nephrol News Issues. 1997;1152- 53
PubMed
Glazer  SCrooks  PShapiro  MDiesto  J Using CQI and the DOQI guidelines to improve vascular access outcomes: the Southern California Kaiser Permanente experience. Nephrol News Issues. 2000;1421- 27
PubMed
National Kidney Foundation, NKF-DOQI clinical practice guidelines for vascular access. Am J Kidney Dis. 1997;30 (4 suppl 3) S150- S191
Not Available, I: NKF-K/DOQI clinical practice guidelines for hemodialysis adequacy: update 2000. Am J Kidney Dis. 2001;37 (1 suppl 1) S7- S64
PubMed
National Kidney Foundation, NKF-DOQI clinical practice guidelines for hemodialysis adequacy. Am J Kidney Dis. 1997;30 (3 suppl 2) S15- S66
Not Available, NKF-DOQI clinical practice guidelines for the treatment of anemia of chronic renal failure: National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis. 1997;30 (4 suppl 3) S192- S240
Gravenstein  NGood  MLBanner  TE Assessment of cardiopulmonary function. Civetta  JMTaylor  RWKirby  RRCritical Care 3rd ed. Philadelphia, Pa Lippincott-Raven Publishers1997;867- 898
Cederholm  LSorenson  JCarlsson  C Thrombosis following percutaneous radial artery cannulation. Acta Anaesthesiol Scand. 1986;30227- 230
PubMed

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