Case 16: Physical Exam

Case 16 Index

Let’s take a look at our patient’s AVF!

The image below shows which of the following:
Collateral veins
Collateral veins are often visualized over the chest or shoulders.
Outflow stenosis of AVF
Though there may be an outflow stenosis present, we cannot identify a stenosis with only visual inspection. Try again!
Aneurysm with overlying ulcer
Correct! Vascular dialysis access aneurysms are commonly seen in these patients. They can be observed over time as long as high risk features (that may lead to rupture) are not present.
*True aneurysms that involve all three layers of the vessel can form more often in AV-fistulas while pseudoaneurysms (focal disruptions of the vessel wall that lead to a blood collection outside the wall contained by fibrous tissue) are more commonly seen in AV-grafts.
*True aneurysms of AV-fistulas are thought to form because of scarring or weaknesses in the vascular wall due to increased venous pressure, repeated puncture at the same site, or immunosuppression.
*Here, we also see an ulcer (break in the skin) over the aneurysm.
Though there may be thrombosis present, we cannot visualize this with this type of image. A silent access (no bruit or thrill) would suggest a thrombosis, which would require a fistulagram and further intervention.
Which of the following is the next best step?
Reassure the patient – his access is working well and will be closely examined at subsequent treatments
Try again! This patient’s AVF finding should not just be monitored over time.
Urgent vascular surgery consultation
Correct! An arteriovenous access ulcer is a surgical emergency. It’s time to get your surgical colleagues involved right away!
Place a pressure dressing over the access immediately
There is not active bleeding, so a pressure dressing is not the best answer choice here. Try again!
Obtain an urgent fistulagram
Though a fistulagram may help us identify stenoses of the AVF, this test will not address the most urgent issue for this patient. Pick again!

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Case 16 Index
Case 16 Introduction