VASCULAR ACCESS CERTIFICATION - PRACTICE
QUESTIONS with 100% CORRRECT ANSWERS
Page 1
,Q1. For a patient with stage 4 chronic kidney disease and a left-sided pacemaker,
which vascular access planning strategy is most consistent with current KDOQI 2019
guidelines?
A. Place a tunneled dialysis catheter in the right internal jugular vein as a bridge to
arteriovenous fistula (AVF) creation.
B. Create a right radiocephalic AVF and allow a minimum of 6 weeks for maturation
before cannulation.
C. Create a left brachial-cephalic AVF to avoid the pacemaker side and preserve the right
arm for future access.
D. Refer for peritoneal dialysis catheter placement as the preferred initial modality to
avoid upper extremity access.
Correct Answer: B. Create a right radiocephalic AVF and allow a minimum of 6
weeks for maturation before cannulation.
Rationale: KDOQI 2019 emphasizes a patient-centered, 'catheter last' approach; AVF
creation is preferred over catheter placement. A right radiocephalic AVF is appropriate
given the left-sided pacemaker (avoid that side for future access). The '6-week rule' is
outdated; maturation is based on clinical and ultrasound criteria, not a fixed time, but a
minimum of 6 weeks is often used as a guide for initial cannulation, though the guideline
allows earlier if criteria met. Option A is catheter-first, C uses the pacemaker side, D is
not necessarily preferred.
Why Wrong:
A - Catheter-first approach contradicts the 'catheter last' principle; if a catheter is
needed, the right IJ is correct but not the preferred initial strategy.
C - Left brachial-cephalic AVF is on the same side as the pacemaker, which can cause
venous stenosis and is discouraged.
D - Peritoneal dialysis is an option but not automatically preferred; the question asks
about vascular access planning for hemodialysis.
Reference: Lok CE, et al. KDOQI Clinical Practice Guidelines for Vascular Access (2019)
. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164.
Q2. A hemodialysis patient presents with a bruit that is continuous but has a low-
pitched, rumbling quality, and the access arm is edematous with dilated superficial
veins. Which hemodynamic principle best explains this presentation?
A. Increased venous resistance due to outflow stenosis causing retrograde diastolic
flow.
B. High-flow access leading to high-output cardiac failure and venous hypertension.
Page 2
, C. Arterial steal syndrome causing distal ischemia and compensatory venous dilation.
D. Aneurysmal degeneration of the venous segment with turbulent, low-resistance
flow.
Correct Answer: A. Increased venous resistance due to outflow stenosis causing retrograde
diastolic flow.
Rationale: Outflow stenosis increases venous resistance, leading to elevated venous
pressure, edema, and collateral vein dilation. The bruit becomes continuous with a low-
pitched rumbling quality because the pressure gradient across the stenosis persists
throughout the cardiac cycle, including diastole. High-output failure (B) would present
with symptoms of heart failure, not isolated arm edema. Steal (C) presents with distal
ischemia, not edema. Aneurysm (D) would present with a pulsatile mass, not diffuse
edema.
Why Wrong:
B - High-output failure presents with systemic symptoms like dyspnea, not isolated
arm swelling.
C - Steal syndrome causes cool, pale, painful hand, not edema and dilated veins.
D - Aneurysm is a focal dilation, not diffuse edema and superficial venous
prominence.
Reference: Beathard GA. Physical examination of the dialysis vascular access. Semin
Dial. 2018;31(3):252-260.
Q3. In a patient with a newly placed brachial-cephalic arteriovenous fistula, which
duplex ultrasound parameter best predicts successful maturation at 6 weeks?
A. Peak systolic velocity > 400 cm/s in the feeding artery.
B. Fistula vein diameter 4 mm and blood flow 500 mL/min.
C. Resistive index < 0.7 in the brachial artery.
D. Absence of accessory veins within 5 cm of the anastomosis.
Correct Answer: B. Fistula vein diameter 4 mm and blood flow 500 mL/min.
Rationale: Multiple studies and the 2019 KDOQI guidelines support that a vein diameter
4 mm and blood flow 500 mL/min at 4-6 weeks post-creation are strong predictors of
successful maturation. These parameters correlate with the ability to cannulate and
achieve adequate dialysis blood flow. The other options are less directly predictive; PSV >
400 cm/s may indicate stenosis, RI is not a standard maturation criterion, and accessory
veins are a correctable issue but not the primary predictor.
Why Wrong:
Page 3
, A - High PSV may suggest stenosis, not maturation; excessive velocity is not a
maturation criterion.
C - Resistive index is not a validated predictor of AVF maturation.
D - Accessory veins can hinder maturation but are not the primary ultrasound
parameter; diameter and flow are key.
Reference: Robbin ML, et al. Hemodialysis arteriovenous fistula maturity: US evaluation.
Radiology. 2002;225(1):59-64.
Q4. During insertion of a tunneled dialysis catheter via the right internal jugular vein,
the guidewire encounters resistance during advancement. What is the most
appropriate immediate action?
A. Withdraw the guidewire and reattempt with a smaller gauge wire.
B. Use fluoroscopy to determine the cause of resistance and adjust the wire direction.
C. Remove the guidewire and perform a venogram to identify the obstruction.
D. Advance the wire with gentle force to overcome the resistance.
Correct Answer: B. Use fluoroscopy to determine the cause of resistance and adjust
the wire direction.
Rationale: Resistance to guidewire advancement during central venous catheter placement
requires immediate fluoroscopic evaluation to identify the cause, such as venous stenosis,
tortuosity, or misdirection into a small vein. Fluoroscopy allows real-time visualization
and safe manipulation of the wire. Removing the wire and performing a venogram (C) is
also reasonable, but the immediate step is to use fluoroscopy to see the wire's position.
Withdrawing and reattempting blindly (A) risks repeated trauma. Forcing the wire (D)
may cause venous perforation.
Why Wrong:
A - Blind reattempt without visualizing the cause can cause vascular injury.
C - Venogram may be needed but the immediate step is to use fluoroscopy to assess
the wire, which is already in place.
D - Forcing a wire against resistance can perforate the vein or cause dissection.
Reference: Vats HS. Complications of central venous catheterization. In: UpToDate. 2023.
Q5. A patient with an arteriovenous graft has a serum potassium of 6.2 mEq/L and
requires urgent hemodialysis. The graft was placed 10 days ago. What is the most
appropriate access for this treatment?
A. Cannulate the graft with a 17-gauge needle and low blood flow.
B. Use a tunneled dialysis catheter inserted in the right internal jugular vein.
C. Use a non-tunneled femoral catheter inserted under ultrasound guidance.
Page 4
QUESTIONS with 100% CORRRECT ANSWERS
Page 1
,Q1. For a patient with stage 4 chronic kidney disease and a left-sided pacemaker,
which vascular access planning strategy is most consistent with current KDOQI 2019
guidelines?
A. Place a tunneled dialysis catheter in the right internal jugular vein as a bridge to
arteriovenous fistula (AVF) creation.
B. Create a right radiocephalic AVF and allow a minimum of 6 weeks for maturation
before cannulation.
C. Create a left brachial-cephalic AVF to avoid the pacemaker side and preserve the right
arm for future access.
D. Refer for peritoneal dialysis catheter placement as the preferred initial modality to
avoid upper extremity access.
Correct Answer: B. Create a right radiocephalic AVF and allow a minimum of 6
weeks for maturation before cannulation.
Rationale: KDOQI 2019 emphasizes a patient-centered, 'catheter last' approach; AVF
creation is preferred over catheter placement. A right radiocephalic AVF is appropriate
given the left-sided pacemaker (avoid that side for future access). The '6-week rule' is
outdated; maturation is based on clinical and ultrasound criteria, not a fixed time, but a
minimum of 6 weeks is often used as a guide for initial cannulation, though the guideline
allows earlier if criteria met. Option A is catheter-first, C uses the pacemaker side, D is
not necessarily preferred.
Why Wrong:
A - Catheter-first approach contradicts the 'catheter last' principle; if a catheter is
needed, the right IJ is correct but not the preferred initial strategy.
C - Left brachial-cephalic AVF is on the same side as the pacemaker, which can cause
venous stenosis and is discouraged.
D - Peritoneal dialysis is an option but not automatically preferred; the question asks
about vascular access planning for hemodialysis.
Reference: Lok CE, et al. KDOQI Clinical Practice Guidelines for Vascular Access (2019)
. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164.
Q2. A hemodialysis patient presents with a bruit that is continuous but has a low-
pitched, rumbling quality, and the access arm is edematous with dilated superficial
veins. Which hemodynamic principle best explains this presentation?
A. Increased venous resistance due to outflow stenosis causing retrograde diastolic
flow.
B. High-flow access leading to high-output cardiac failure and venous hypertension.
Page 2
, C. Arterial steal syndrome causing distal ischemia and compensatory venous dilation.
D. Aneurysmal degeneration of the venous segment with turbulent, low-resistance
flow.
Correct Answer: A. Increased venous resistance due to outflow stenosis causing retrograde
diastolic flow.
Rationale: Outflow stenosis increases venous resistance, leading to elevated venous
pressure, edema, and collateral vein dilation. The bruit becomes continuous with a low-
pitched rumbling quality because the pressure gradient across the stenosis persists
throughout the cardiac cycle, including diastole. High-output failure (B) would present
with symptoms of heart failure, not isolated arm edema. Steal (C) presents with distal
ischemia, not edema. Aneurysm (D) would present with a pulsatile mass, not diffuse
edema.
Why Wrong:
B - High-output failure presents with systemic symptoms like dyspnea, not isolated
arm swelling.
C - Steal syndrome causes cool, pale, painful hand, not edema and dilated veins.
D - Aneurysm is a focal dilation, not diffuse edema and superficial venous
prominence.
Reference: Beathard GA. Physical examination of the dialysis vascular access. Semin
Dial. 2018;31(3):252-260.
Q3. In a patient with a newly placed brachial-cephalic arteriovenous fistula, which
duplex ultrasound parameter best predicts successful maturation at 6 weeks?
A. Peak systolic velocity > 400 cm/s in the feeding artery.
B. Fistula vein diameter 4 mm and blood flow 500 mL/min.
C. Resistive index < 0.7 in the brachial artery.
D. Absence of accessory veins within 5 cm of the anastomosis.
Correct Answer: B. Fistula vein diameter 4 mm and blood flow 500 mL/min.
Rationale: Multiple studies and the 2019 KDOQI guidelines support that a vein diameter
4 mm and blood flow 500 mL/min at 4-6 weeks post-creation are strong predictors of
successful maturation. These parameters correlate with the ability to cannulate and
achieve adequate dialysis blood flow. The other options are less directly predictive; PSV >
400 cm/s may indicate stenosis, RI is not a standard maturation criterion, and accessory
veins are a correctable issue but not the primary predictor.
Why Wrong:
Page 3
, A - High PSV may suggest stenosis, not maturation; excessive velocity is not a
maturation criterion.
C - Resistive index is not a validated predictor of AVF maturation.
D - Accessory veins can hinder maturation but are not the primary ultrasound
parameter; diameter and flow are key.
Reference: Robbin ML, et al. Hemodialysis arteriovenous fistula maturity: US evaluation.
Radiology. 2002;225(1):59-64.
Q4. During insertion of a tunneled dialysis catheter via the right internal jugular vein,
the guidewire encounters resistance during advancement. What is the most
appropriate immediate action?
A. Withdraw the guidewire and reattempt with a smaller gauge wire.
B. Use fluoroscopy to determine the cause of resistance and adjust the wire direction.
C. Remove the guidewire and perform a venogram to identify the obstruction.
D. Advance the wire with gentle force to overcome the resistance.
Correct Answer: B. Use fluoroscopy to determine the cause of resistance and adjust
the wire direction.
Rationale: Resistance to guidewire advancement during central venous catheter placement
requires immediate fluoroscopic evaluation to identify the cause, such as venous stenosis,
tortuosity, or misdirection into a small vein. Fluoroscopy allows real-time visualization
and safe manipulation of the wire. Removing the wire and performing a venogram (C) is
also reasonable, but the immediate step is to use fluoroscopy to see the wire's position.
Withdrawing and reattempting blindly (A) risks repeated trauma. Forcing the wire (D)
may cause venous perforation.
Why Wrong:
A - Blind reattempt without visualizing the cause can cause vascular injury.
C - Venogram may be needed but the immediate step is to use fluoroscopy to assess
the wire, which is already in place.
D - Forcing a wire against resistance can perforate the vein or cause dissection.
Reference: Vats HS. Complications of central venous catheterization. In: UpToDate. 2023.
Q5. A patient with an arteriovenous graft has a serum potassium of 6.2 mEq/L and
requires urgent hemodialysis. The graft was placed 10 days ago. What is the most
appropriate access for this treatment?
A. Cannulate the graft with a 17-gauge needle and low blood flow.
B. Use a tunneled dialysis catheter inserted in the right internal jugular vein.
C. Use a non-tunneled femoral catheter inserted under ultrasound guidance.
Page 4
