Buzz in the axilla: a new physical sign in hemodialysis forearm graft evaluation

Abstract

The value of physical signs in predicting flow rates or polytetrafluoroethylene (PTFE) hemodialysis graft survival is not well known. Simultaneous physical examination and flow measurements were performed in 67 dialysis patients with PTFE grafts over a period of 1 month. Physical signs included the presence and location of a palpable thrill, location and auscultatory nature of the bruit, and presence or absence of a pulsation. Patients were followed up for 1 year to detect the time to failure defined by angioplasty, clotting, or surgical revision. There was a fair correlation between physical signs and graft flow rates. In a multivariate model, systolic blood pressure, location of the thrill, and patient age were the best predictors of graft flow. During follow-up, there were 68 graft failures (30 grafts, angioplasty alone; 38 grafts, thrombosis followed by interventional or surgical revisions). The median survival of a graft without a thrill in the axilla was 154 days compared with 321 days when a thrill was present (P = 0.05, log-rank test). Dialysis graft physical examination is a useful test to predict graft flows, as well as graft failure. The single best test is the location of the thrill along the venous limb of the graft. Average flow rates for no thrill, thrill but distal to the midarm, and axillary buzz were approximately 500, 750, and 1,000 mL/min, respectively. This single physical sign also correlated with subsequent graft failure and should be incorporated into physical examinations of all dialysis grafts.