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Gerrickens MW, Yadav R, Vaes RH, Scheltinga MR. A scoping review on surgical reduction of high flow arteriovenous haemodialysis access. J Vasc Access 2024; 25:728-744. [PMID: 36428291 DOI: 10.1177/11297298221138361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Volume flow (Qa) > 1.5-2 l /minQa in arteriovenous accesses may be associated with high flow related systemic or locoregional complications. A variety of surgical techniques are advocated for Qa reduction. Aim of this scoping review is to provide an overview of available evidence regarding the efficacy of this broad spectrum of interventions for Qa reduction in patients with a high flow haemodialysis access. PubMed and Embase were searched according to PRISMA-guidelines. Studies on invasive management of HFA were selected. Inclusion required an English description of surgical techniques in human HFAs including pre- and postoperative access flow-values. Sixty-six studies on 940 patients (mean age 56 years (3-90 years), male 62%, diabetes mellitus 26%, brachial artery-based arteriovenous access 65%) fulfilled inclusion criteria. Performed techniques were banding (58%), revision using distal inflow (12%), plication/anastomoplasty (10%), graft interposition (5%), proximal radial artery ligation (3%), aneurysm repair (4%), or miscellaneous other techniques (8%). Definition of HFA, work-up, indication for surgery and intraoperative monitoring were diverse. All techniques reduced Qa on the short term (mean drop 0.9-1.7 l/min). Secondary access patency rates varied between 70% and 93% (mean follow-up 15 (0-189) months). Definitions of success and recurrence varied widely precluding a comparison of efficacy of techniques. Patient specific factors legitimizing invasive treatment for HFA are discussed. Recommendations on reporting standards when dealing with HFA surgery are provided. In conclusion, the present report on the current management of high flow access does not allow for drawing any definite conclusions due to a lack of standardization in definition, indications for surgical intervention and techniques. Randomized trials comparing different Qa reducing techniques in symptomatic patients are warranted, as are trials comparing a wait-and-see approach versus Qa reduction in asymptomatic patients. As an overview of the variety of techniques was lacking, this scoping review might serve as a map for future researchers.
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Affiliation(s)
| | - Reshabh Yadav
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Roel Hd Vaes
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Marc Rm Scheltinga
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
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Evans A, Nguyen B, Nassar G. Discovery of a large axillary artery vascular malformation during the evaluation of a patient with hemodialysis access-induced distal ischemia: Implications on pathophysiology and management. Semin Dial 2021; 34:380-383. [PMID: 34291828 DOI: 10.1111/sdi.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/17/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
A patient with a 6-year-old left upper arm brachial cephalic AVF presented with symptoms of hemodialysis access-induced distal ischemia (HAIDI). Physical exam findings showed a well-developed AVF, but compression of the AVF aggravated arm pain and induced diffuse erythema of the left upper extremity. Angiographic evaluation disclosed the presence of a large axillary artery vascular malformation (AVM) as well as distal forearm hypo-perfusion. We elected to publish this case report to describe the interesting physical exam findings related to the AVM, and discuss HAIDI treatment options that are peculiar to this case. We also highlight the importance of thorough vascular evaluation prior to AV access creation as well as during the investigation of the cause of HAIDI.
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Affiliation(s)
- Andrew Evans
- Renal Division, Department of Internal Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Binh Nguyen
- North Shepherd Dialysis Access Management Center; Nephrology, Dialysis and Transplantation Associates, The Kidney Institute, Houston, Texas, USA
| | - George Nassar
- Renal Division, Department of Internal Medicine, Houston Methodist Hospital, Houston, Texas, USA.,North Shepherd Dialysis Access Management Center; Nephrology, Dialysis and Transplantation Associates, The Kidney Institute, Houston, Texas, USA.,Weill Cornell Medicine, Houston, Texas, USA
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Sheaffer WW, Hangge PT, Chau AH, Alzubaidi SJ, Knuttinen MG, Naidu SG, Ganguli S, Oklu R, Davila VJ. Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER): A Review of the Available Literature and Brief Overview of Alternate Therapies in Dialysis Associated Steal Syndrome. J Clin Med 2018; 7:E128. [PMID: 29843483 PMCID: PMC6025613 DOI: 10.3390/jcm7060128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/25/2018] [Accepted: 05/28/2018] [Indexed: 11/16/2022] Open
Abstract
Dialysis associated steal syndrome (DASS) is a relatively rare but debilitating complication of arteriovenous fistulas. While mild symptoms can be observed, if severe symptoms are left untreated, DASS can result in ulcerations and limb threatening ischemia. High-flow with resultant heart failure is another documented complication following dialysis access procedures. Historically, open surgical procedures have been the mainstay of therapy for both DASS as well as high-flow. These procedures included ligation, open surgical banding, distal revascularization-interval ligation, revascularization using distal inflow, and proximal invasion of arterial inflow. While effective, open surgical procedures and general anesthesia are preferably avoided in this high-risk population. Minimally invasive limited ligation endoluminal-assisted revision (MILLER) offers both a precise as well as a minimally invasive approach to treating both dialysis associated steal syndrome as well as high-flow with resultant heart failure. MILLER is not ideal for all DASS patients, particularly those with low-flow fistulas. We aim to briefly describe the open surgical therapies as well as review both the technical aspects of the MILLER procedure and the available literature.
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Affiliation(s)
- William W Sheaffer
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
| | - Patrick T Hangge
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Anthony H Chau
- Division of Vascular Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
| | - Sadeer J Alzubaidi
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - M-Grace Knuttinen
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sailendra G Naidu
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Suvranu Ganguli
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Rahmi Oklu
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Victor J Davila
- Division of Vascular Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
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Abstract
INTRODUCTION In this article, we will review the clinical symptoms of dialysis access steal syndrome (DASS), evaluation, treatment options, and our approach and treatment algorithm. METHODS We reviewed the literature discussing different aspects of DASS including its epidemiology, pathogenesis, clinical presentation, evaluation and management options. RESULTS DASS is the most dreaded complication of access surgery. Although the incidence is low, all providers caring for dialysis patients should be aware of this problem. Symptoms can range from mild to limb threatening. Although various tests are available, the diagnosis of DASS remains a clinical one and requires thoughtful management to have the best outcomes. CONCLUSIONS Multiple treatment options exist for steal. We present diagnostic evaluation and management algorithm.
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Plication for the Treatment of a Radio-Cephalic Fistula with Ulnar Artery Steal. Int J Artif Organs 2016; 39:90-3. [DOI: 10.5301/ijao.5000481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2016] [Indexed: 11/20/2022]
Abstract
Purpose Generally the steal syndrome occurs in proximal arterial-venous fistulas and only exceptionally with distal vascular access because of the high number of arteries supplying the hand. We describe a rare case of steal syndrome of a proximalized distal radio-cephalic fistula stealing from both the radial and ulnar artery through the palmar arch. Methods An 86 year old man was admitted because of a cyanotic, swollen left hand with trophic lesions at the third finger. He had a latero-terminal radio-cephalic fistula performed in 2006 with subsequent proximalization performed four years later after failure of the first one. Duplex ultrasound examination showed a high flow within the fistula (2080 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch and an angiography excluded stenosis along the radial artery. Results We treated the steal syndrome through a plication technique that was performed with careful flow variations measurement, under duplex evaluation, during the surgical procedure. That procedure was effective to maintain the fistula flow and obtain the symptoms relief. The patient was evaluated the day after the intervention and after 10 weeks. The clinical examination highlighted the resolution of hand ischemia. The Duplex Ultrasound examination showed a lower flow within the fistula (1060 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch with a three-phase flow. Dialysis access from the fistula was never interrupted from immediately after surgery to the present date. Conclusions Plication is an effective technique for treatment of steal syndrome requiring a short operative time and it is related to satisfying post-operative results
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Dilator-assisted Banding and Beyond: Proposing an Algorithm for Managing Dialysis Access-associated Steal Syndrome. J Vasc Access 2016; 17:299-306. [DOI: 10.5301/jva.5000570] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2016] [Indexed: 11/20/2022] Open
Abstract
Purpose Dialysis access-associated steal syndrome (DASS) is a major complication of arteriovenous hemodialysis accesses. Although its underlying pathology is diverse, it is most often associated with excessive access flow. Dilator-assisted banding (DAB) is a simple flow-reduction technique that we described previously. This report is to illustrate the expansion of DAB and analyze the outcome of DAB in managing DASS. Methods From February 2011 to April 2015, 30 patients underwent DAB for DASS. Their relevant clinical data were retrospectively reviewed or prospectively collected, and further analyzed statistically. Results Of the 30 patients, 23 had an arteriogram and 3 required angioplasty ± stent placement for inflow artery stenosis. Besides intraluminal DAB (12/30), this report also included extraluminal DAB (14/30) and open fistula reduction plus DAB (4/30). After DAB, the severity scores of DASS were reduced from 2.8 ± 0.4 to 0.2 ± 0.4 for the fistula group (n = 24, p<0.001) and from 3.0 ± 0.0 to 1.2 ± 1.2 for the graft group (n = 6, p = 0.041). DAB was effective in all but two graft patients who subsequently underwent proximalization of arterial inflow (PAI) that resulted in resolution of DASS. During follow-up of 18.7 ± 14.5 months (range 1-50), all accesses remained functional. At 24-months post-DAB, the primary patency, primary-assisted patency and secondary patency rates of the fistula group were 72%, 91% and 100%, respectively. Conclusions DAB is a simple, effective and versatile approach for managing DASS. PAI may be employed for rescue or as primary choice when banding is ineffective. Based on our data and the literature, an algorithm is proposed for managing DASS.
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