AV Fistula US Technologist Worksheet St Vincents Riverside Southside Clay St Johns Imaging Center Arlington ER Westside ER Beach ER Optimal Forbes Southside Clay Mandarin Westside St Johns Town Center Orange Park Patient Name: MMI: Age: History/Symptoms: AV Fistula Anatomy: Date Fistula Created: For all indications: 1st Measurement 2nd Measurement 3rd Measurement Arterial Flow Volumes (mL/min) Venous Flow Volumes (mL/min) Signs of mature AV fistula: flow volume ≥500-600 mL/min. Signs of >50% stenosis include: draining vein flow volume <600 mL/min or ≥25% decrease compared to prior. For all indications: Only for maturity indication: PSV (cm/sec) Diameter (mm) Vessel Depth (mm) not applicable Artery 2 cm Proximal to Anastomosis At Artery/Vein Anastomosis not applicable not applicable Vein 5 cm From Anastomosis (Proximal) Vein 10 cm From Anastomosis (Mid) Vein 15 cm From Anastomosis (Distal) Signs of mature AV fistula: Vein diameter ≥ 4-6 mm, vein ≤6 mm below skin surface. Signs of >50% stenosis include: >50% luminal narrowing at grayscale imaging, peak velocity >400-500 cm/sec at stenosis; velocity ratio >3.0 AVF anastomosis or >2.0 draining vein. For all indications: None Nonocclusive Occlusive Chronic Subclavian / Common Femoral Vein None Nonocclusive Occlusive Chronic DVT Axillary / Femoral Vein None Nonocclusive Occlusive Chronic Brachial / Popliteal Veins For all indications document diameter & distance from anastomosis of any accessory veins extending off the draining vein: Sonographer's Impression: Sonographer's Name, Date & Time:

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Not Intended for Treatment Planning MI-0641B
(Revised 6/2025) Tech Wrksht - "AV Fistula US Chrtform"