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\title{The Sensitivity and Specificity of Clinical Examination of the Hemodialysis Arterial-Venous Fistula (AVF) as Compared to Angiography}
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             \author[1]{Awad  Magbri}

             \author[2]{Awad  Magbri}

             \author[3]{Eussera  El-Magbri}

             \author[4]{Taha  El-Magbri}

             \author[5]{Ji-Yank Sophie  Lee}

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\date{\small \em Received: 8 December 2015 Accepted: 4 January 2016 Published: 15 January 2016}

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\begin{abstract}
        


Background and Objectives: Physical examination of the hemodialysis arterial-venous fistula (AVF) is convenient and inexpensive, and can often detect common problems associated with hemodialysis access. Routine systematic physical examination of the fistula by the dialysis staff with each treatment may allow early detection of problems that are commonly associated with mature fistula. This avoiding missed treatments and emergent situations. Dialysis access stenosis is the most common cause of access dysfunction. Physical examination is an important method in the assessment of stenotic lesions. The purpose of this study is to evaluate the two simple maneuvers in physical examination of the AVF (pulse augmentation and pressure assessment inside the fistula and collapsibility of the fistula on arm elevation) and compare them with the gold standard angiography.

\end{abstract}


\keywords{AVF (arteriovenous fistula), angiography, augmentation of the AVF, collapsibility of the AVF, interventional nephrologist, stenosis of the outflow tra}

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\let\tabcellsep& 	 	 		 \par
The Sensitivity and Specificity of Clinical Examination of the Hemodialysis Arterial-Venous Fistula (AVF) as Compared to Angiography Awad Magbri ? , Ji-Yank Sophie Lee ? , Eussera El-Magbri ? , Mariam El-Magbri ? \& Taha El-Magbri ¥ Abstract-Background and Objectives: Physical examination of the hemodialysis arterial-venous fistula (AVF) is convenient and inexpensive, and can often detect common problems associated with hemodialysis access. Routine systematic physical examination of the fistula by the dialysis staff with each treatment may allow early detection of problems that are commonly associated with mature fistula. This avoiding missed treatments and emergent situations. Dialysis access stenosis is the most common cause of access dysfunction. Physical examination is an important method in the assessment of stenotic lesions. The purpose of this study is to evaluate the two simple maneuvers in physical examination of the AVF (pulse augmentation and pressure assessment inside the fistula and collapsibility of the fistula on arm elevation) and compare them with the gold standard angiography. I. Background and Objectives hysical examination of the hemodialysis arterialvenous fistula (AVF) is convenient and inexpensive, and can often detect common problems associated with hemodialysis access \hyperref[b0]{(1)}\hyperref[b1]{(2)}\hyperref[b2]{(3)}\hyperref[b3]{(4)}\hyperref[b4]{(5)}.\par
Routine physical examination of the fistula by the dialysis staff with each treatment may allow early detection of problems that are commonly associated with mature fistula, thus avoiding missed treatments and emergent situations. Dialysis access stenosis is the most common cause of access dysfunction. Therefore, physical examination is an important method in the assessment of stenotic lesion \hyperref[b0]{(1,}\hyperref[b5]{(6)}\hyperref[b6]{(7)}\hyperref[b7]{(8)}\hyperref[b8]{(9)}.\par
The 2006 National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/ DOQI) guidelines recommend that physical examination (monitoring) be performed on all mature AVFs on a weekly basis \hyperref[b9]{(10,}\hyperref[b10]{11)}. Such monitoring is also recommended by the 2008 Society for Vascular Surgery practice guidelines \hyperref[b11]{(12)}. We strongly agree that hemodialysis AVF should be examined at every hemodialysis treatment. This requires that all clinical staff who are directly involved in the care of hemodialysis patients be familiar with the basic techniques used to examine the fistula.\par
The purpose of this study is to evaluate the two simple maneuvers in physical examination of the AVF (pulse augmentation and pressure assessment inside the fistula and collapsibility of the fistula on arm elevation) compared to the gold standard (angiography). 
\section[{II. Subjects and Methods}]{II. Subjects and Methods}\par
A total of 118 patients dialyzed via a mature AVF were included. The patients were referred to the dialysis access center of Pittsburgh because of dysfunctional AVF. There were 27 right arm fistulas (3 radial-cephalic and 24 upper arms AVF), and 91 left arms AVF (15 radial-cephalic AVF, and 76 upper arms AVF), Table-1. The age range of the patients is 22 yrs to 92 yrs, with a mean of 63.2 yrs. 55\% of the patients were males and 53\% were diabetics. 91\% of patients were hypertensive, and 4.3\% have peripheral arterial disease. Clinical examination of the dialysis AVF includes;\par
1. Pulse augmentation and pressure assessment in the fistula is graded into 1,2 2. Good augmentation of the pulse pressure and AVF is soft by palpation. 3. No augmentation and high pulse pressure in the AVF 4. Collapsibility of the fistula on arm elevation is also graded to; 5. The AVF is completely collapsed on arm elevation 6. The AVF is hyperpulsatile and not collapsed on arm elevation.\par
Pulse augmentation is assessed by complete occlusion of the access several centimeters away from the arterial anastomosis and evaluation of the stenght of the pulse as well as palpating the fistula without obstructing the outflow tract and assesses the pressure inside the fistula. The fistula is considered normal when there is good augmentation of the pulse upstream from the occluded finger \hyperref[b6]{(7)}. The pulse pressure as assessed by palpation is not increased in this case.\par
Collapsibility of the AVF is assessed by elevating the arm of the fistula above the heart and examination of the normal collapsing of the fistula. These two simple maneuvers are correlated with the angiogram findings of the AVF \hyperref[b6]{(7)}. The test was considered abnormal when the fistula remained pump after arm elevation. Then angiography is used to assess the fistula. Both retrograde and antegrade angiography were done to evaluate the access from the feeding artery to the right atrium (C-arm 9900 vascular package; General Electric, Milwaukee WI).\par
Two interventional nephrologists (IN) were involved, separately, in physical examination and angiographic examination and interpretation. To offset the bias, the IN who is carrying out the angiographic studies does not know about the results of the physical examination. The findings of the physical examination and angiography were then analyzed at the end of the study. 
\section[{a) Statistical Analyses}]{a) Statistical Analyses}\par
Chi-square with Fisher's exact test for the twotailed p value was used to analysis the dichotomous data from the physical examination and angiographic findings. A p value of <.05 was considered as significant. The Cohen's k value was used to measure the level of agreement beyond chance between the diagnoses made by physical examination and angiography \hyperref[b12]{(13,}\hyperref[b13]{14,}\hyperref[b14]{15)}. It is a robust statistic tool useful for either interrater or intrarater reliability testing. It can range from -1 to +1, where 0 represents the amount of agreement that can be expected from random chance, and 1 represents perfect agreement between the raters. Kappa value of <0 as indicating no agreement and 0.01-0.20 as none to slight, 0.21-0.40 as fair, 0.41-0.60 as moderate, 0.61-0.80 as substantial, and 0.81-1.00 as most perfect agreement. The kappa was designed to take account of the possibility of guessing. 
\section[{III. Results}]{III. Results}\par
In this study only the outflow stenosis was assessed and compared to the finding on angiography. 74 patients were found to have significant out flow stenoses by angiography (>50\% stenosis). Physical examination using collapsibility of the AVF detected 69/74 stenoses (93.3\%), and augmentation and pulse pressure assessment detected 66/70 patients (94.3\%), (Tables \hyperref[tab_3]{-2, 3}). The specificity of the augmentation and collapsibility were 79.1\% and 79.5\%, respectively. Collapsing of the fistula missed 5 patients who had side branches to divert blood away from the main fistula.\par
Analysis of forearm and upper arm fistulas revealed no significant difference in the diagnostic accuracy of these two physical examination maneuvers in detecting stenosis. Sensitivity and specificity of forearm and upper arm fistula were identical. Therefore, no breakdown of the results by fistula type was done.\par
The sensitivity, specificity, positive and negative predictive value of the 2 maneuvers was calculated and is shown in Tables-2, 3.\par
The overall sensitivity of the augmentation and pulse pressure palpation when compared to angiography is 94.3\%, with specificity of 79.1\%, positive predictive value of the test of 86.4\%, and negative predictive value of 90.3\%, Table-2. The p value of the two-tailed fisher's test was highly significant <0.0001. There was a good agreement beyond chance between the physical examination and the angiography in the diagnosis of outflow stenosis (Cohen's k value for agreement k=0.749).\par
When collapsibility of the fistula is compared with angiography, the overall sensitivity of the maneuver is 93.3\%, with specificity of 79.5\%, positive and negative predictive values of 88.5\% and 87.5\% respectively, Table  {\ref -}3. The p value of the two-tailed fisher's test was highly significant <0.0001. There was a good agreement beyond chance between the physical examination and the angiography in the diagnosis of outflow stenosis (Cohen's k value for agreement k=0.742). 
\section[{IV. Discussion}]{IV. Discussion}\par
Physical examination is a good and convenient tool in the assessment of vascular access dysfunction. A few reports have studied and evaluated its usefulness in the detection of access stenosis when compared to the gold standard, angiography, \hyperref[b8]{(9,}\hyperref[b14]{15)}. The results of this study agreed with the work of Choi et al \hyperref[b7]{(8)}, and Mishler et al \hyperref[b15]{(16)}. These investigators found that physical examination reliably diagnosed significant outflow stenosis of the AVF when compared to angiography. While, these workers showed the strength of physical examination, their work was limited by cofounders; like study design, the sample size, lack of independent assessment of the angiographic images, and bias, since the same physician who performed the physical examination read the angiography images. Also, they did not report on the sensitivity, specificity of the physical examination, nor the agreement between the physical examination and angiography.\par
Both this study and that of Asif et al, avoided all these cofounders \hyperref[b7]{(8)}. Our study and that of Asif have clearly shown that physical examination has high sensitivity, specificity, and can be a useful tool for detecting stenosis in the dialysis access. We used Cohen's k values to ascertain the agreement between the physical examination and angiography. We found a robust correlation between physical examination and angiographic findings.\par
We undoubtedly, demonstrated high sensitivity and specificity (93 to 94\% and 79\%, respectively) of the physical examination to detect significant outflow stenosis in the dialysis access (AVF). The high sensitivity and specificity make physical examination a valuable tool to screen for the presence of out flow stenosis in mature AVF. This makes physical examination a valuable tool for streamline patients with dysfunctional fistula to vascular access center by the staff in a timely manner. Because physical examination of the vascular access is inexpensive and available, it should be adopted, universally, by all staff members who care for hemodialysis patient.\par
Performing physical examination during angioplasty of the stenosis can assist in the success of balloon angioplasty. It can also help the interventionalist as to the site of cannulation, thus, potentially save time, minimize morbidity, and reduce cost.\par
The limitations of this study are that physical examinations are carried out by well versed interventionalist who has long experience on vascular access evaluation. This may not be applied for the general nephrologists who often see the patients on the dialysis machine. The study also investigated only outflow obstruction in mature fistula as related to physical examination. Since the study has a small sample size, and was carried out in one facility may limit its applicability to all other dialysis facilities. 
\section[{V. Conclusion}]{V. Conclusion}\par
Dialysis access stenosis is the most common cause of access dysfunction. Physical examination of the hemodialysis vascular access is inexpensive and valuable tool in the diagnosis and localization of stenosis. Referring patients with dysfunctional access can avoid missed treatments, emergent situations, and can impact cost and inconvenience. \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.6057471264367816\textwidth}P{0.07816091954022988\textwidth}P{0.1660919540229885\textwidth}}
\tabcellsep RCAVF\tabcellsep Upper arm AVF\\
Right arm\tabcellsep 3\tabcellsep 24\\
Left arm\tabcellsep 15\tabcellsep 76\\
\multicolumn{3}{l}{RCAVF-radial-cephalic arterial-venous fistula}\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.6289017341040462\textwidth}P{0.007369942196531791\textwidth}P{0.10809248554913294\textwidth}P{0.10563583815028901\textwidth}}
\multicolumn{2}{l}{Angiography positive}\tabcellsep Angiography negative\tabcellsep \\
No Augmentation \& high pressure\tabcellsep 66\tabcellsep 10\tabcellsep PPV = 86.4\%\\
Good augmentation \& fistula soft\tabcellsep 4\tabcellsep 38\tabcellsep NPV = 90.3\%\\
\multicolumn{2}{l}{Sensitivity = 94.3\%}\tabcellsep Specificity = 79.1\%\tabcellsep Prevalence = 59.3\%\\
PPV = Positive predictive value\tabcellsep \tabcellsep \tabcellsep \\
NPV = Negative predicative value\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{Two-tailed Fisher's exact test (p value <0.0001)}\tabcellsep \tabcellsep \\
(Cohen's k value for agreement k=0.749).\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.5230769230769231\textwidth}P{0.007005494505494506\textwidth}P{0.1004120879120879\textwidth}P{0.21950549450549453\textwidth}}
\tabcellsep \tabcellsep \tabcellsep Year 2016\\
\tabcellsep \tabcellsep \tabcellsep Volume XVI Issue III Version I\\
\tabcellsep \tabcellsep \tabcellsep D D D D ) F\\
\tabcellsep \tabcellsep \tabcellsep (\\
\multicolumn{2}{l}{Angiography positive}\tabcellsep Angiography negative\tabcellsep \\
AVF not collapsible\tabcellsep 69\tabcellsep 9\tabcellsep PPV = 88.5\%\\
AVF collapsible\tabcellsep 5\tabcellsep 35\tabcellsep NPV = 87.5\%\\
\multicolumn{2}{l}{Sensitivity = 93.3\%}\tabcellsep Specificity = 79.5\%\tabcellsep Prevalence = 62.7\%\\
PPV = Positive predictive value\tabcellsep \tabcellsep \tabcellsep \\
NPV = Negative predictive value\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{Two-tailed Fisher's exact test (p value <0.0001)}\tabcellsep \tabcellsep \\
\multicolumn{2}{l}{(Cohen's k value for agreement k=0.742).}\tabcellsep \tabcellsep \end{longtable} \par
  {\small\itshape [Note: © 2016 Global Journals Inc. (US)]} 
\caption{\label{tab_3}Table 3 :}\end{figure}
 			\footnote{© 2016 Global Journals Inc. (US)} 			\footnote{The Sensitivity and Specificity of Clinical Examination of the Hemodialysis Arterial-Venous Fistula (AVF) as Compared to Angiography} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}