**7. Routine surveillance**

While fistula access is recommended for all patients with ESRD on hemodialysis, complications such as stenosis and resultant thrombosis lead to access failure. Therefore, surveillance of hemodialysis access is mandated by regulatory agencies (NKF: K/DOQI, 2006). Prior research attempts to substantiate a surveillance protocol for AV grafts have failed, showing no improvement in the outcome of thrombosis. There is a paucity of data on the benefit of surveillance for fistulas (Allon 2009). Once the factors that cause venous stenosis in fistulas are known, early detection provides the necessary framework to develop protocols to mitigate the onset of intimal hyperplasia. Treatment trials in future studies could then be initiated to change factors that contribute to venous stenosis.

Although there is a lack of adequate surveillance methods to detect fistula stenosis prior to thrombosis, there are some clues in the physical exam that may prove helpful in clinical practice. The physical examination may be the best test as to fistula adequacy for dialysis. Pre-procedure physical examination has been shown to accurately detect significant venous stenosis. The pre-dialysis physical exam of the fistula to detect significant stenosis may include: inspection, palpation from the anastomosis all the way to the chest wall, and auscultation. The characteristics of the pulse such as pulsatile, normal or weak, and if the thrill or bruit is continuous or discontinuous should be noted. Pulse augmentation and arm elevation tests may also be preformed to detect inflow or outflow stenosis. These elements of the physical exam have been reproduced and substantiated to correlate with venous stenosis (Asif, 2007).
