A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia

Measuring perianastomotic pressure to identify patients at high risk for dialysis-associated steal syndrome

OBJECTIVE

Dialysis access-associated steal syndrome (DASS) is one of the most serious complications of hemoaccess surgery. Treatment algorithms involve significant morbidity; a tool to reliably identify patients at risk who could benefit from interventions at time of operation would be useful. We present a strategy of using perianastomotic pressure (PAP) measurement to identify patients who may be at high risk of developing DASS.

METHODS

Patients who underwent dialysis access creation between January 1, 2018, and September 30, 2022, at our institution were reviewed. Beginning in October 2019, we developed a strategy of measuring systolic pressure at the arterial anastomosis intraoperatively. A ratio of this value compared with the systemic systolic pressure was calculated. In patients believed to be at high risk for developing DASS based on clinical findings, selective banding of the access was performed intraoperatively to augment distal perfusion.

RESULTS

Of 857 total patients, 36 (4.2%) developed clinically significant DASS, defined as requiring operative treatment, either intraoperatively or during follow-up (mean, 76 days; range, 0-602 days). DASS was more common for femoral-based accesses (6/12 [46.2%]) compared with upper extremity accesses (30/840 [3.6%]; P < .001). No patients who underwent radiocephalic arteriovenous fistula or infraclavicular axillary arteriovenous graft construction developed DASS. There was no difference in DASS for upper extremity arteriovenous fistulas (20/576, 3.47%) vs AV grafts (10/264, 3.79%; P = .82). There were 216 patients who had PAP measured intraoperatively. Fourteen (6.5%) of these 216 patients developed DASS requiring intervention in follow-up. The mean PAP ratio of these 14 patients was 0.395 vs 0.557 for the 202 patients who did not (95% confidence interval, 0.07-0.25; P = .001). Seventeen patients who had a low PAP ratio with poor distal perfusion underwent intraoperative banding, which improved the mean PAP ratios from a mean of 0.33 to 0.58. Despite banding, 3 of these 17 patients (17.6%) in this high-risk subgroup went on to develop DASS postoperatively. The calculated mean PAP ratio in patients who either developed DASS postoperatively or underwent prophylactic banding intraoperatively was 0.37, which was significantly lower than the mean ratio of 0.57 in the control group (P = .001).

CONCLUSIONS

Low PAP ratios (<0.50) identified patients at increased risk for DASS, but prophylactic banding did not always prevent the occurrence of DASS in select patients. Because steal is a dynamic phenomenon, intraoperative conditions are not always going to reflect later adaptation. Nonetheless, PAP measurement may identify a subgroup of patients warranting procedural modification or closer postoperative physiological monitoring.

Long term outcomes of 'Christmas Tree' banding for haemodialysis access induced distal ischemia: A 13-year experience

BACKGROUND

The reduction in distal arterial flow following arteriovenous fistula (AVF) creation can cause a perfusion deficit known as haemodialysis access induced distal ischemia (HAIDI). Various techniques have been advocated to treat this difficult problem with varying success. We present the long-term outcomes following a novel banding technique.

METHODS

46 patients in this cohort from 2008 to 2021 underwent a novel banding procedure using a Dacron™ patch shaped with one slit-end and saw-tooth edges (resulting in a 'Christmas-tree' pattern) to provide a ratchet mechanism to progressively constrict the fistula outflow. Real-time finger perfusion pressure monitoring allowed an accurate reduction in AVF flow whilst increasing distal arterial perfusion pressure. Baseline characteristic were recorded and Kaplan-Meier survival curves were obtained to calculate the post-intervention primary, assisted primary and secondary patency.

RESULTS

29 patients presented with rest pain and 11 presented with tissue loss due to distal ischemia. The post-intervention primary access patency was 100%, 98%, 78% and 61% at 30, 60 and 180 days and 1 year respectively. Complete resolution of symptoms was achieved in 74% (n = 34) of patients and a partial response needing no further intervention was achieved in 11% (n = 5) of patients. A Youden index calculation suggested that digital pressures of 41 mm Hg or lower in an open AVF were highly sensitive for symptomatic hand ischemia whereas pressures greater than 65 mm Hg ruled out distal ischemia.

CONCLUSION

'Christmas-tree' banding with on table finger systolic pressures is not only an efficacious and durable method for treating HAIDI but also preserves fistula patency.

A scoping review on surgical reduction of high flow arteriovenous haemodialysis access

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.

Rapid progression of finger gangrene in a hemodialysis patient: A case report

Severe hemodialysis access-induced distal ischemia is an uncommon complication after arteriovenous fistula creation. Finger amputation is rare and generally does not involve the entirety of the digit. The distal revascularization interval ligation procedure has become less commonly used for hemodialysis access-induced distal ischemia over the past decade. The procedure typically requires general anesthesia, greater saphenous vein harvest, and brachial artery ligation. We describe a 64-year-old female with hypertension, diabetes mellitus, and end-stage renal disease on hemodialysis via a well-functioning brachiocephalic arteriovenous fistula who developed rapid progression of finger gangrene. She underwent the distal revascularization interval ligation procedure, followed by finger amputations. The finger amputations healed within 6 months of the distal revascularization interval ligation procedure and the fistula was preserved at 2-year follow-up.

Efficacy of Revision Using Distal Inflow in Patients with Symptomatic Dialysis Access-Associated Steal Syndrome

Objectives: In this study, we aim to assess the efficacy of revision using distal inflow (RUDI) in patients with symptomatic dialysis access-associated steal syndrome (DASS). Materials and Methods: All consecutive patients who were diagnosed with grade 3 or 4 DASS and have undergone RUDI in 4 years were included in this study. Results: In total, 35 patients were included in this study; participants had a mean age of 47.5±7.52 years and 54% (n=19) were males. As per our findings, significant improvement was noted in terms of paresthesia (81.2%, p-value: 0.012), coolness (79.4%, p-value: 0.006), pain (78.1%, p-value: 0.006), discoloration (76.4%, p-value: 0.044), paresis (71.4%, p-value: 0.016), and ulcer healing (50%, p-value: 0.044). Gangrene did not further progress in all patients (n=35). Reduction in fistula flow rate after RUDI was 57.5% (682±121 ml/min, p-value: 0.001). Digital systolic pressure was noted to improve by 71.4% (60±9.2 mmHg, p-value: 0.002) after RUDI. Peak systolic velocity increased in both ulnar (66.1±8.2 cm/s, p-value: 0.04) and radial (64.2±7.6 cm/s, p-value: 0.024) arteries of the wrist. Cumulative patency of RUDI graft was 100%, 91.4%, and 85.7% at 3, 6, and 12 months, respectively. Conclusion: RUDI has resulted in significant improvements in terms of DASS symptoms. Using a native vein as conduit, RUDI should be considered a procedure of choice for patients with high-flow DASS.

Maintenance and Salvage of Hemodialysis Access

Many end-stage kidney failure patients require hemodialysis as a life-sustaining treatment. Hemodialysis access via arteriovenous fistula or graft creation is preferred over long-term dialysis catheters, but intervention to maintain patency and prevent access failure is common. Endovascular and open surgical techniques are both utilized to address the underlying etiology of failure. Endovascular options include balloon angioplasty, angioplasty with stenting, and drug-eluting stents. Open revision is commonly needed for recurrent stenosis, aneurysmal or pseudoaneurysmal change, hemodialysis access-induced distal ischemia, and infection. Treatment plans should be guided by patient's individualized goals of care and require a multidisciplinary approach to the management of this complex disease.

Recognizing dialysis access steal syndrome with central vein stenosis as arteriovenous fistula complication: A case report

INTRODUCTION

Ischemic consequences of hemodialysis arteriovenous (AV) access are infrequent, yet they can cause substantial limb impairment or even loss. Ischemia can be caused by many factors, but the most common etiology is reduced blood supply to the distal extremities due to blood flow through the AV fistula (AVF) or AV graft. We reported a case of dialysis access steal syndrome (DASS) in a diabetes mellitus patient.

CASE REPORT

A 69-year-old diabetic man with left brachiocephalic AVF on his left upper arm has main complaint of left-hand pain, swelling, and coldness. There are also trophic darkening changes in the distal first, third, and fourth fingers. A duplex doppler examination revealed a normal functional AV shunt with bidirectional distal retrograde inflow. There was also significant stenosis at axillary vein. So, a diagnosis of DASS with suspicion of distal anastomosis stenosis at axillary vein was made. The patient underwent digital amputation and surgical plication of the AV shunt. He also underwent percutaneous transluminal angioplasty at the level of axillary. After 10 days of care, he was later discharged.

CLINICAL DISCUSSION

DASS is life and limb-threatening clinical disorder. Not only does the discomfort make it difficult for the patient to tolerate hemodialysis, but the ischemia can cause tissue necrosis and the eventual loss of fingers and possibly the patient's life. Doppler ultrasonography is a non-invasive technique that provides important information about vascular anatomy and hemodynamics. Aggressive treatment, including limb surgery and intensive blood glucose regulation, will result in favourable results.

CONCLUSIONS

DASS is a rare condition usually encountered in hemodialysis patients with AVF. Proper diagnosis and management are needed to get an optimal outcome for the patient.

Late Basilic Vein Superficialization Combined with Revision Using Distal Inflow (RUDI) Operation to Treat a Symptomatic High Flow Fistula

BACKGROUND

Vascular access (VA)-related high flows (HF) are common with brachial artery based fistulas. Flow-reduction procedures are indicated in symptomatic patients or asymptomatic ones with flows >2 L/min. However concomitant issues increase their complexity. We describe a case of a patient suffering congestive heart failure as a result of HF brachial-basilic fistula >3 L/min. A simultaneous late basilic vein transposition and revision using distal inflow (RUDI) was performed.

METHODS

A large diameter untransposed arterialized basilic vein was carefully and completely mobilized up to the proximal upper arm. After harvesting an autologous great saphenous vein (GSV) segment, a new inflow anastomosis was performed in the proximal ulnar artery. At the final stage, and after tunneling the mobilizing basilic vein in a subcutaneous semicircular configuration, an end-to-end anastomosis joining the two stumps (basilic vein outflow portion and GSV inflow arterial portion) was performed. A decision-making process in order to reach this complex option is discussed. Results Access flow and cardiac output were greatly attenuated following our approach. After a mean follow-up of 9 months no VA complications were observed, with flow still detected below 2 L/min. All cardiac symptoms and ultrasound investigations improved.

CONCLUSION

Multiple VA issues including HF pose a risk for abandonment and a challenge for the vascular surgeon. An effort toward increasing the "upper extremity life span" is advised.

Distal revascularization and interval ligation for dialysis access-related ischemia is best performed using arm vein conduit

OBJECTIVE

Distal revascularization and interval ligation (DRIL) is an effective approach to the management of hemodialysis access-related ischemia that offers both symptom relief and access salvage. The great saphenous vein (GSV) has been the most commonly used conduit. However, the use of an ipsilateral arm vein will allow for performance of the operation with the patient under regional anesthesia and might result in lower harvest site morbidity than the GSV. We sought to determine the suitability of DRIL using an arm vein compared with a GSV conduit.

METHODS

All patients who had undergone DRIL from 2008 to 2019 were retrospectively identified in the electronic medical records. The characteristics and outcomes of those with an arm vein vs a GSV conduit were compared using the Wilcoxon log-rank and χ² tests. Access patency was examined using Kaplan-Meier methods, with censoring at lost to follow-up or death.

RESULTS

A total of 66 patients who had undergone DRIL for hand ischemia were included in the present study. An arm vein conduit was used in 40 patients (median age, 65 years; 25% male) and a GSV conduit in 26 patients (median age, 58 years; 19% male). No significant differences in comorbidities were found between the two groups, with the exception of diabetes mellitus (arm vein group, 78%; GSV group, 50% GSV; P = .02). No difference in the ischemia stage at presentation was present between the groups, with most patients presenting with stage 3 ischemia. Also, no differences in patency of hemodialysis access after DRIL between the two groups were found (P = .96). At 12 and 24 months after DRIL, 86.9% (95% confidence interval [CI], 68.3%-94.9%) and 82.0% (95% CI, 61.3%-92.3%) of patients with an arm vein conduit had access patency compared with 93.8% (95% CI, 63.2%-99.1%) and 76.9% (95% CI, 43.0%-92.2%) of those with a GSV conduit, respectively. All but one patient had symptom resolution. The incidence of wound complications was significantly greater in the GSV group than in the arm vein group (46% vs 11%; P = .003). DRIL bypass had remained patent in all but one patient in each group, with a median follow-up of 18 months (range, 1-112 months) in the arm vein conduit group and 15 months (range, 0.25-105 months) in the GSV conduit group.

CONCLUSIONS

DRIL procedures using an arm vein have advantages over those performed with the GSV. In our series, symptom resolution and access salvage were similar but distinctly fewer wound complications had occurred in the arm vein group. Additionally, the use of an arm vein conduit avoids the need for general anesthesia. If an ipsilateral arm vein is available, it should be the conduit of choice when performing DRIL.

Severe hemodialysis access-induced distal ischemia may be associated with poor survival

BACKGROUND

Some hemodialysis patients develop hemodialysis access-induced distal ischemia due to insufficient loco-regional perfusion pressure and consequent poor arterial flow. We hypothesized that patients with severe hemodialysis access-induced distal ischemia had worse survival compared with patients with mild or no hemodialysis access-induced distal ischemia.

METHODS

This single-center retrospective observational cohort study included three groups of prevalent hemodialysis patients with an upper extremity vascular access between 2006 and 2018. Symptomatic patients had signs and symptoms of hemodialysis access-induced distal ischemia and low digital brachial indices (<60%) and were divided into a mild (Grade I-IIa) and a severe hemodialysis access-induced distal ischemia (IIb-IV) group. The control group consisted of hemodialysis patients without signs of hemodialysis access-induced distal ischemia with digital brachial indices ≥60%. Factors potentially related to 4-year survival were analyzed.

RESULTS

Mild hemodialysis access-induced distal ischemia-patients displayed higher digital brachial indices (n = 23, 41%, ±3) compared with severe hemodialysis access-induced distal ischemia-patients (n = 28, 24%, ±4), whereas controls had the highest values (n = 48, 80%, ±2; p < .001). A total of 44 patients (44%) died during follow-up. Digital brachial index (hazards ratio 0.989 [0.979-1.000] p = .046) was related to overall mortality following correction for presence of arterial occlusive disease (hazards ratio 2.28 [1.22-4.29], diabetes (hazards ratio 2.00 [1.07-3.72], and increasing age (hazards ratio 1.03 [1.01-1.06] as was digital pressure (hazards ratio 0.990 [0.983-0.998], p = .011). Overall survival was similar in mild hemodialysis access-induced distal ischemia and controls (2-year, 79% ±5; 4-year, 57% ±6, p = .818). In contrast, 4-year survival was >20% lower in patients with severe hemodialysis access-induced distal ischemia (2-year 62%± 10; 4-year 34% ± 10; p = .026).

CONCLUSION

Presence of severe hemodialysis access-induced distal ischemia may be associated with poorer survival in hemodialysis patients. Lower digital brachial index values are associated with higher overall mortality, even following correction for other known risk factors.

A systematic review of distal revascularization and interval ligation for the treatment of vascular access-induced ischemia

OBJECTIVE

Vascular access-induced ischemia remains a rare but significant complication of arteriovenous fistulas. Distal revascularization and interval ligation (DRIL) is one form of treatment. However, its collated efficacy through a systematic review is yet to be established.

METHODS

An electronic and systematic search of the literature in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Library from 1966 to 2017 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Quality assessment of the articles was performed using the Oxford Critical Appraisal Skills Programme, and the recommendation for practice was examined through the National Institute for Health and Care Excellence. Data of treated cases, success, time to ischemia, follow-up, age, sex, diabetes mellitus, fistula type, conduit type, and grade of ischemia were extracted and subjected to a pooled variance-weighted random-effects model.

RESULTS

Twenty-two studies (n = 459 individuals) were subjected to DRIL. Time to ischemia was 196 days (interquartile range, 30-600 days). Ischemia grade 3/4 (52%) was the most common presentation. The overall success (grades 1-4) was 81% (95% confidence interval, 80.9%-82.5%) during a mean and median follow-up of 22.2 months (interquartile range, 1-60 months) and 18 months, respectively. The conduit of choice was the great saphenous vein (n = 300/459 [65%]), and bypass thrombosis was highest in the polytetrafluoroethylene group (n = 19/44 [43%]).

CONCLUSIONS

DRIL with adequate long-term outcomes is an effective technique for the treatment of vascular access-induced ischemia.

Revision Using Distal Inflow for the Treatment of Dialysis Access Steal Syndrome: A Systematic Review

The aim of this systematic review is to establish the efficacy of revision using distal inflow (RUDI) on the primary endpoints of complete dialysis access steal syndrome (DASS) resolution and arteriovenous fistula (AVF) longevity. An electronic search of literature from 1966 to 2017 in CINAHL, Medline, Embase and the Cochrane library according to PRISMA standards was conducted. Quality evaluations and recommendations for practice were examined. Data on power, age, gender, comorbidities, arterial inflow, conduit material, fistulae type, follow-up, failure incidence, ischaemia grade, modality of diagnosis, morbidity and mortality were subjected to pooled analysis of prevalence at a 95% confidence interval (CI). Eleven studies involving 130 individuals with a median age of 57 [interquartile ranges (IQR), 54-65] and equal gender distribution were conducted. Of the patients with diabetes mellitus (67.3%), the most common type of AVF with DASS was brachiocephalic AVF (73.7%). Overall, the prevalence of success was 82.0% (95%CI, 74.4%-89.6%) over 12 months (IQR, 1-40 months). Grade 3 ischaemia was the most common type of DASS (49.2%). Grade 4 had the worst outcomes compared with grades 2 and 3. The overall morbidity was 3% with no mortality. Overall, RUDI is an effective treatment for various grades of DASS and their longevity.

Pilot study using intraoperative fluorescence angiography during arteriovenous hemodialysis access surgery

INTRODUCTION:

In this pilot study, we used indocyanine green fluorescence angiography during hemodialysis access surgery. The aim was to evaluate its relevance as a diagnostic tool to visualize changes in hand microperfusion.

PATIENTS AND METHODS:

In this prospective single-center study, 47 adult patients (33 male, 14 female) with renal disease (24 preemptive, 23 endstage) were enrolled. Surgical creation of an arteriovenous fistula was performed (22 forearm, 25 upper arm). Microperfusion of the ipsilateral hand and fingers was evaluated intraoperatively using indocyanine green fluorescence angiography. We compared the cumulated microperfusion parameters ingress (In) and ingress rate (InR) before and after opening of the anastomosis. To compare the dimension of microcirculatory decline, we calculated the ratios of the parameters (RatioIn and RatioInR) after to those before anastomosis opening.

RESULTS:

The cumulated microperfusion parameters In and InR showed a significant decrease after completion of anastomosis and declamping. This effect has been seen in all patients for the hand and for each finger consecutively. During follow-up (mean 4.6, range 3-11 months), 5 patients (10.6%) complained about hemodialysis access-induced distal ischemia. The ratio of intraoperative microperfusion in those five hemodialysis access-induced ischemia patients was significantly lower compared to asymptomatic patients (RatioIn 0.23 vs 0.58, p = 0.001, and RatioInR 0.25 vs 0.62, p = 0.003).

CONCLUSION:

Intraoperative fluorescence angiography could visualize the deterioration of ipsilateral hand microperfusion after surgical creation of an arteriovenous fistula. It seems to be a promising tool to detect patients at risk for hemodialysis access-induced distal ischemia early in the peri- or even intraoperative stage.

[Vascular steal syndrome due to the creation of an arteriovenous shunt for hemodialysis, patient information and nephrologist responsibility]

Although responsibility is a fundamental determinant in medical practice, physicians are generally unfamiliar with its principles. The same is true for disclosure requirements and requests for compensation in the event of physical injury. We report on a representative survey of iatrogenic complications that may arise after the implementation of vascular access for haemodialysis and that illustrate's the physician's responsibility and obligation to inform the patient. Vascular access steal syndrome is a serious complication of arteriovenous fistulas, and physicians may not be sufficiently aware of the likelihood of its occurrence. Diabetes (via medial calcific sclerosis) and placement in the brachial artery (with excessively high flow rates) are the main risk factors. The precariousness of vascular status in dialysis patients threatens to increase the incidence of this complication. The therapeutic challenge is to resolve ischemic events while maintaining vascular access. The presence of gangrene of the fingers is a formal indication for surgery. The borderline between therapeutic risk (the risk inherent in a medical procedure and which cannot be controlled) and liability for injury is blurred. The French Patient's Rights Act (voted on March 4th, 2002) emphasizes the physician's duty to inform the patient of treatment-associated risks and the fact that the physician now bears the burden of proof. We suggest that a patient information sheet on the benefits and risks of vascular access should be published on the French Society of Nephrology, Dialysis and Transplantation's website.

Dialysis-associated steal syndrome (DASS)

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.