Indications for surgical treatment of angioaccess-induced arterial "steal"

ACR Appropriateness Criteria® Dialysis Fistula Malfunction

The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Iatrogenic Arteriovenous Fistula Secondary to Percutaneous Coronary Intervention Causing Severe Decompensated Heart Failure

Congestive heart failure has long been a well-known cause of both morbidity and mortality for thousands of people worldwide. Consequences of decompensated heart failure are systemic and widespread, including but not limited to pulmonary edema, dyspnea, hypoxia, peripheral edema, and end-organ hypoperfusion. Common etiologies of congestive heart failure include systemic hypertension, coronary artery disease, longstanding alcohol abuse, valvular dysfunctions, and myocarditis. While the vast majority of congestive heart failure cases are secondary to one of these common etiologies, there is a subset of cases that cannot be traced to any of these causes and are most often grouped under the category of idiopathic. One rarely seen etiology of decompensated heart failure is an arteriovenous fistula, whether naturally occurring or iatrogenic. We report a case of an iatrogenic AV fistula secondary to percutaneous coronary intervention causing severe decompensated heart failure that was successfully treated with surgical ligation.

Dialysis associated steal syndromes. A narrative review

BACKGROUND

To review contemporary concepts in the genesis of Dialysis Access Steal Syndrome (DASS) and its current management.

METHODS

An electronic search of literature from 1960 to 2020 in Pubmed and the Cochrane library was conducted and practice guidelines were examined. Search terms included dialysis, steal, ischemia, access and ESRD. Clinical presentation, pathophysiology, risk factors, diagnostic techniques and management outcomes of extremity ischemia following dialysis access creation were reviewed.

RESULTS

Symptomatic steal occurs in 4-10% of patietns after creation of hemodialysis access creation. Risk factos include brachial based fistula, diabetes, female sex, coronary heart disease, cerebrovascular disease, tobacco use, age more than 60 and hypertension. Diagnosis is mainly clinical and can be aided by non invasive testing. Correction o finflow stenosis, Distal revasulatisation with interval ligation, revision using distal inflow or other techniques are useful for fistula preservation.

CONCLUSIONS

Dialysis associated steal syndromes have a complex haemodynamic causation. Clinical presentation is diagnostic; however when the diagnosis is uncertain adjunctive noninvasive perfusion tests, duplex and other imaging amy be required. Management is guided by anatomic, patient and disease-related considerations.

Cost-effectiveness analysis of radiobasilic and brachiobasilic arteriovenous fistulas in hemodialysis patients

We evaluated the cost and efficacy of radiobasilic and brachiobasilic arteriovenous fistula (AVF) methods in terms of forearm autogenous arteriovenous access in hemodialysis patients. We used a decision tree to compare the cost-effectiveness of proximal radiobasilic AVF (pRBAVF) and brachiobasilic AVF (BBAVF), considering the mean direct medical costs and patency rates. The overall mean cost of pRBAVF per patient (1767.59 Turkish lira [TL]) was lower than that of BBAVF (1877.99 TL). Also, the mean patency duration per patient was higher for pRBAVF (25.72 months) than BBAVF (20.21 months). The incremental cost-effectiveness ratio (ICER) showed that pRBAVF was 20.04-fold more effective than BBAVF. The monthly ICERs also favored pRBAVF, which was less costly and more effective. The pRBAVF provided clinical and economic benefits for hemodialysis patients requiring forearm autogenous arteriovenous access. pRBAVF was more effective in terms of patency than BBAVF, and was also less expensive.

Skin perfusion pressure for predicting access-related hand ischemia following arteriovenous fistula surgery based on the brachial artery

BACKGROUND

Access-related hand ischemia (ARHI) is a major complication of arteriovenous fistula (AVF). This study aimed to assess the predictive efficacy of skin perfusion pressure (SPP) measurement for ARHI by examining the relationship between SPP and ARHI development and progression after AVF surgery.

METHODS

Twenty-five patients (16 men and 9 women) who underwent AVF surgery based on the brachial artery between January 2018 and December 2018 were included. The pre- and postoperative SPP values were measured on the day of surgery. ARHI occurrence and severity were measured within 3 days and at 6 months after surgery. Receiver operating characteristic curve analysis was used to evaluate the prediction model of ARHI, and the cutoff points for the calculated coefficients were determined.

RESULTS

There was a significant correlation between the occurrence of immediate ARHI and the SPP gradient (p = 0.024). An SPP gradient value >50 mmHg had sensitivity and specificity values of 53.85% and 91.67%, respectively, in predicting the occurrence of immediate ARHI. A postoperative SPP <48 mmHg was significantly correlated with the occurrence of 6-month ARHI (p = 0.005), with sensitivity and specificity values of 71.43% and 83.33%, respectively.

CONCLUSION

The SPP gradient and postoperative SPP values may be effective clinical predictors of ARHI occurring immediately and 6 months after surgery, respectively, with high specificity. These findings could allow clinicians to diagnose and begin early interventions to help prevent ischemic tissue damage in hemodialysis patients following AVF surgery.

ASDIN white paper: Assessment and management of hemodialysis access-induced distal ischemia by interventional nephrologists

Although not common, hemodialysis access-induced distal ischemia is a serious condition resulting in significant hemodialysis patient morbidity. Patients with signs and symptoms suggestive of hand ischemia frequently present to the general and interventional nephrologist for evaluation. In order to care for these cases, it is necessary to understand this syndrome and its management. Most cases can be managed conservatively without intervention. Some cases requiring intervention may be treated using techniques within the scope of practice of the interventional nephrologists while other cases require vascular surgery. In order for the interventional nephrologists to evaluate and manage these cases in a timely and appropriate manner, practice guidelines are presented.

New Horizons in Dialysis Access: Approach to Hand Ischemia

Hand ischemia is a relatively common complication of hemodialysis arteriovenous (AV) access. Clinical manifestations frequently start with pale and cold ipsilateral hand. Symptoms can progress to pain during dialysis and can eventually lead to tissue necrosis and gangrene if not addressed in a timely fashion. Comprehensive physical examination of the hand, AV access, and comparing it with the contralateral hand will assist in differentiating hand ischemia from carpal tunnel syndrome, osteoarthritis of the hand, and others. There are several treatment options for hand ischemia based on the severity of symptoms. Conservative management with careful monitoring can be applied in early stages. However, if symptoms persist or worsen, a full arteriogram of the ipsilateral extremity should be performed to evaluate for the presence of arterial stenosis. Angioplasty of the arterial stenosis, if present, will frequently lead to the resolution of symptoms. There are several percutaneous and surgical treatment options for hand ischemia, if no arterial stenosis was found or angioplasty does not relieve symptoms. We discuss in this article these treatment options in detail. Treatment goal is to improve hand ischemia symptoms while maintaining hemodialysis AV access and preserving patient's hand. Access ligation remains a treatment of last resort.

Use of a temporary shunt to preserve the patency of a hemodialysis graft while performing ipsilateral axillo-femoral bypass

Increased blood flow in the subclavian artery feeding a vascular access for hemodialysis can rarely induce steal phenomena in the vertebral and internal mammary artery leading to potentially life-threatening conditions. On the contrary, transient interruption of blood flow in the subclavian artery feeding a dialysis arteriovenous fistula can theoretically induce access thrombosis. Here, we describe a technical maneuver preserving continuous ipsilateral upper arm access flow when constructing a unilateral axillo-femoral polytetrafluoroethylene bypass operation for critical limb ischemia in a hemodialysis patient.

Long-term outcomes of the 'primary extension technique' in the prevention of Steal syndrome

PURPOSE

To report our 13 years of experience with the 'primary extension technique' for the prevention of dialysis-associated steal syndrome.

METHODS

All diabetic patients undergoing upper arm autogenous elbow fistula formation using the primary extension technique between September 2001 and September 2014 at a single centre were included. At follow-up all patients were evaluated for patency, adequacy of needling and the presence or absence of steal symptoms. In primary extension technique, the fistula is formed by anastomosing the median cubital vein with the proximal radial or ulnar artery just below the brachial artery bifurcation.

RESULTS

In total, 64 operations of the primary extension technique were included in this study. All patients were diabetic. Primary failure was 5%, follow-up 23-84 months. Nine patients (14%) developed cephalic vein thrombosis. In these cases, the basilic vein was successfully transposed to the existing fistula. In eight patients (12.5%), the cephalic vein required superficialisation. In three patients, the flow was preferentially into the basilic vein with poor maturation of cephalic vein. Of these three patients, there was a small proximal cephalic vein in one patient and stenosis in the other two patients. One patient who developed dialysis-associated steal syndrome is included in the results as they were listed for primary extension technique fistula formation but in fact did not have their fistula formed using primary extension technique. Instead, the anastomosis was formed proximal to the bifurcation of the brachial artery. Symptoms improved with revision of the fistula.

CONCLUSION

Our 13-year experience demonstrates that the primary extension technique is a safe and effective procedure for fistula formation. Patency rates are comparable to brachio-cephalic and brachio-basilic fistulas and primary extension technique is effective in the prevention of dialysis-associated steal syndrome.

Skin Microcirculatory Changes in Relation to Arteriovenous Fistula Maturation

Maturation of arteriovenous fistula (AVF) involves complex vascular remodeling. In this study, we evaluated the changes of skin microvascular perfusion over the extremity with AVF maturation using the laser Doppler fluximetry (LDF). A total of 45 patients with chronic kidney disease, Stages IV-V, were included; they had undergone AVF creation from July 2014 to June 2016 at our institute. The measurement of skin microvascular perfusion was accomplished proximal and distal to the fistula anastomosis site: pre- and post-operative day 1, week 2, week 6, and week 12. Thirty-two patients with mean age of 55.6 had achieved AVF maturation. There were 40.6% radial-based and 59.4% brachial-based AVF. There was a 32.8% reduction of mean skin perfusion distal to the fistula by day 1 compared to the baseline perfusion; however, perfusion increased 47% by week 2 compared to day 1 and no dramatic change was subsequently noted. There was an increase of mean skin perfusion, proximal to fistula anastomosis, over 12 weeks with 35.8% at day 1 from the baseline. However, the changes of the mean skin perfusion were not statistically significant. There was no significant relation of skin perfusion changes with the type of fistula, diabetes mellitus, hypertension, and hyperlipidemia. LDF successfully detected the subclinical change of skin microvascular perfusion in relation to AVF creation. Reduction of skin perfusion distal to the fistula suggests that in patients with existing perfusion inadequacy of extremities, they may experience ischemic symptoms as early as day 1 postoperation, and require close monitoring for distal limb ischemic-related complications.

Use of the distal radial artery remnant for autogenous radial-cephalic wrist fistula after radial artery harvest for coronary artery bypass grafting

Harvesting of the radial artery is a common technique used to provide conduit for coronary artery bypass graft surgery. We report the case of a patient with exhausted left upper extremity access options, history of left upper extremity dialysis access-associated steal syndrome, and prior right radial artery harvest for coronary artery bypass graft who received an autogenous distal radial artery remnant to cephalic vein wrist fistula.

Stenotic ligature: a simple technique for managing distal hypoperfusion ischemic syndrome following arteriovenous fistulas

Introduction. Distal Hypoperfusion Ischemic Syndrome (DHIS) is a multifactorial debilitating condition causing peripheral ischemia and potentially tissue necrosis. In an effort to further refine its surgical treatment we aim to describe a modified, simple and reliable technique for managing DHIS in patients with arteriovenous fistulas. Materials and Methods. Twenty-nine consecutive patients with DHIS operated by a single surgical team over a period of 7 years were included in the study. All patients underwent the same surgical technique: stenotic ligature. Outcomes were analyzed clinically and the effectiveness of the procedure was proven using McNemar test. Clinical variables were statistically analyzed in SPSS 17.0 for Windows. Results. The technique we used consists in performing a stenosing ligature on the vein, using a 0-silk suture, and adjusting the suture in order to achieve either a radial pulse or capillary pulse, while maintaining a good thrill at palpation of the vein. The procedure was successful in 83% of patients proved by immediate symptomatic relief. Paired data analysis showed significant decrease of all symptoms: cold extremity (p=0,021), paraesthesia (p less 0,001), pain (p less 0,001). History of coronary artery disease, arteriopathy or the absence of radial pulse is statistically correlated with an increased risk of developing DHIS. Conclusions. Stenotic ligature is a simple, cheap and reliable technique for managing DHIS with lower septic risks which can be easily performed under local anesthesia.

A new endovascular technique for the treatment of dialysis-associated steal syndrome

Background Dialysis access-associated steal syndrome is a major complication of arteriovenous fistula creation whereby the low-resistance venous conduit shunts arterial inflow through the anastomosis, resulting in clinically significant distal artery insufficiency. Herein, we describe a case of severe steal phenomenon with gangrene of a digit following placement of an arteriovenous fistula that was treated with a novel, entirely endovascular technique. To our knowledge, this was the first totally endovascular approach to dialysis access-associated steal syndrome. Methods Catheterization of the right subclavian, axillary, and brachial arteries was performed. A short 5-Fr sheath was exchanged for a long destination 6-Fr sheath and placed in the proximal brachial artery. An arteriogram showed no stenosis of the arterial system, but did show substantial steal phenomenon with inflow to the arteriovenous fistula, instead of the forearm. We placed a stent graft in the brachial artery across the anastomosis such that the graft covered 3/4 of the length of the opening of the anastomosis. Results Immediately after placement of the stent graft the clinical picture improved dramatically. Patient was followed for 15 months after this procedure until her demise for unrelated causes without ever experiencing dialysis access-associated steal syndrome and with a patent and functional arteriovenous fistula. Conclusion We present a patient with severe dialysis access-associated steal syndrome complicated by third fingertip gangrene, which was successfully treated using a completely endovascular technique. This novel endovascular approach enabled a high-risk patient to avoid open surgery, preserve her limb, and maintain the function of her arteriovenous fistula.

[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.

Modified Distal Revascularization with Interval Ligation Procedure for Steal Syndrome after Arteriovenous Fistula Creation for Hemodialysis Access

Patients diagnosed with steal syndrome after hemodialysis access surgery have a few options for symptom relief while maintaining vascular access. These include fistula lengthening, banding, distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI) or proximalization of the arterial inflow (PAI). Two cases are described in which a modified DRIL procedure without interval ligation was used to relieve steal syndrome, leaving the arterial supply of an ischemic hand not entirely dependent upon a bypass. Furthermore, a review of the literature is presented in order to elucidate this relatively new treatment option as a viable means to improve hand perfusion while maintaining a functional fistula.

Radiobasilic Versus Brachiobasilic Transposition on the Upper Arm to Avoid Steal Syndrome

BACKGROUND

Although the proximal radial artery has been reported as an alternative inflow to prevent steal syndrome, brachiobasilic fistula has been reported to be associated with steal syndrome in 10-20% of cases. We aimed to compare proximal radiobasilic arteriovenous fistula (AVF) with brachiobasilic AVFs on the upper arm in terms of steal syndrome and outcomes.

MATERIAL AND METHODS

We used our institutional operative record database to identify 94 patients in whom brachiobasilic AVF (n=40) and radiobasilic AVF (n=54) were placed between January 2009 and December 2013. Postoperative complications such as steal syndrome, venous hypertension, and aneurysm were recorded.

RESULTS

Steal syndrome was determined to occur less frequently in the radiobasilic AVF group (0% vs. 10%, P=0.03). The rates of other complications (bleeding, aneurysm, venous hypertension) between the 2 groups were similar, as were the patency rates.

CONCLUSIONS

Radiobasilic AVF was effective in reducing steal syndrome, with similar early and late outcomes.

Surgical interventions for late complications of arteriovenous fistulas

Our aim was to determine the most effective surgical treatment for arteriovenous fistula (AVF) complications after all other methods of salvage have failed. We evaluated 110 patients for 139 complications that occurred after the initial AVF placement and for whom surgical intervention was the last hope for retaining fistula access. Vascular steal syndrome and venous hypertension were the most common complications seen in our patients. The anastomoses of 17 of the vascular steal syndrome cases were narrowed either by stitches or by a polytetrafluoroethylene graft. The second most performed revision surgery was excision of the aneurysm and repair with primary suturing, followed by excision of the aneurysm and interposition grafting. Successful surgical outcomes were achieved in 111 of 139 procedures after revision surgery without constructing a new AVF. AVF salvage surgery is of paramount importance in order to increase the patency rate, which prolongs survival and increases the patient's quality of life.

Modified Miller Banding Procedure for Managing High-flow Access and Dialysis-associated Steal Syndrome

Purpose

Both high-flow vascular access (VA) and dialysis-associated steal syndrome are serious complications requiring a flow reduction technique. We adopted the minimally invasive limited ligation endoluminal-assisted revision (MILLER) banding procedure with some modifications to control the high blood flow and steal syndrome during VA procedures and retrospectively assessed the outcome.

Methods

Seven patients with high-flow access (access flow >1400 ml/min) and five patients with steal syndrome (with pain, coldness, or cyanosis) were treated using the MILLER banding method. Flow volume of the brachial artery was monitored using Doppler ultrasonography during the banding procedure. In patients with steal syndrome, the finger probe of a pulse oximeter was attached to a finger on the ipsilateral side, and the peripheral oxygen saturation (SpO2) was monitored.

Results

In the high-flow group, the mean access blood flow (Qa) decreased from 2043 ± 463 ml/min (mean ± SD) to 1248 ± 388 ml/min (p<0.001). In the steal syndrome group, the SpO2 value improved in all steal syndrome patients after banding. Symptoms were almost relieved in two steal syndrome patients. The Qa in the steal group decreased from 997 ± 867 to 548 ± 376 ml/min (p = 0.12). The secondary patency rates of the high-flow and steal groups at 6 months were 83.3% and 50%, respectively.

Conclusions

The MILLER banding procedure with intraoperative access flow monitoring is effective to treat high-flow VA and steal syndrome.

Radiological diagnosis of dialysis-associated complications

In daily clinical practice, the radiologist in the context of diagnosis often faces dialysis-associated complications. The complications are numerous and range from infections, catheter dysfunctions, haematomas, cardiovascular diseases, digital ischaemia, and pseudoaneurysms to shunt stenosis. In this pictorial essay, we take a close look at the imaging diagnostics of the most common complications in dialysis patients. Teaching Points • The occurrence of venous stenosis in haemodialysis patients is up to 41 %. • Catheters usually have a fibrin sheath that can be rinsed but not aspirated. • The steal phenomenon occurs in 75-90 % of patients with a shunt system. • Arterial pseudoaneurysms can cause a number of complications.

Chronic Hemodialysis Access-Induced Distal Ischemia (HAIDI): Distinctive form of a Major Complication

Purpose

Hemodialysis access-induced distal ischemia (HAIDI) is an uncommon but potentially devastating complication. HAIDI is classified as acute, subacute and chronic based upon the time of onset. The aim of this study was to determine the prevalence, severity, patients’ characteristics and the underlying etiologic mechanism of chronic HAIDI using color Doppler ultrasonography (CDUS).

Methods

Between June and August 2010, 676 hemodialysis patients with arteriovenous access (AVA) were evaluated for clinical evidence of chronic HAIDI. In the case–control part of the study, CDUS findings were compared between ischemic patients and asymptomatic matched controls. Also, patients with chronic HAIDI were followed up until February 2014, access ligation, kidney transplantation or death.

Results

Eighteen chronic HAIDI patients were diagnosed (2.66%). Cold hand and cold sensation were the most common signs and symptoms of hand ischemia, respectively. Fifteen patients were classified in stage 1. Patients with proximal autogenous arteriovenous fistula, younger age, more previous AVAs and less access age were more likely to develop chronic HAIDI. Excessive fistula flow was found in the majority of ischemic patients (83.3%). The mean fistula flow was significantly higher in cases compared to controls (p=0.001). Eleven patients with chronic HAIDI were successfully treated by conservative measures alone until the end of follow-up ( n=3), kidney trans-plantation ( n=4) or death ( n=4).

Conclusions

CDUS is a useful adjunctive diagnostic tool to determine the etiology of chronic HAIDI. Conservative measures combined with close follow-up can be used as the first step in the management of chronic HAIDI patients with mild symptoms.

Chronic kidney disease and dialysis access in women

Chronic kidney disease currently affects one in nine Americans and over 500,000 have progressed to failure requiring kidney replacement therapy, with nearly 45% being women. Clinical Practice Guidelines have been developed in an effort to synthesize the latest literature, particularly randomized controlled trials, to assist clinical decision making. Women have different levels of kidney function than men at the same level of serum creatinine and may also lose kidney function over time more slowly than men. Although the arteriovenous fistulae have long been recognized as the preferred access for hemodialysis, women are less likely to initiate dialysis with an arteriovenous fistula in place. In addition, the female sex is regarded as a risk factor for access failure as well for complications such as steal. This article reviews treatment of women with chronic kidney disease, focusing on the difficulties they are perceived to have with dialysis access.

Prophylactic distal revascularization and interval ligation procedure during femoral vein transposition fistula creation in patients at high risk for ischemic complications

Femoral vein transposition arteriovenous fistula (FVt AVF) is a viable autologous option when upper extremity dialysis access sites have become compromised. High volume flow through the AVF can lead to ischemic complications, including steal syndrome (SS), and may threaten access and limb viability. Risk factors for SS include: age >60 years, female sex, diabetes, atherosclerosis, hypertension, and previous limb procedures. Two dialysis patients, who were at high risk for SS in their lower extremities as assessed during the preoperative evaluation for an elective FVt AVF, had a distal revascularization and interval ligation (DRIL) procedure concurrently performed. At 42 and 24 months from their respective surgeries, both patients are reliably using their lower extremity autologous access sites and have not developed any signs or symptoms of ischemia. DRIL may represent an effective surgical strategy that can prophylactically be used to minimize the incidence of ischemic complications during FVt AVF in carefully selected, high-risk patients.

Distal revascularization and interval ligation: a primer for the vascular and interventional radiologist

Dialysis-associated steal syndrome is a clinically significant complication associated with the creation of dialysis grafts or fistulae. The distal revascularization and interval ligation (DRIL) procedure is a surgical procedure, which has been used to treat patients with hand ischemia secondary to arterial "steal" from dialysis accesses. This article will review the dialysis-associated steal syndrome and the history, anatomy, and clinical results of the DRIL procedure.

Angioplasty of ulnar or radial arteries to treat critical hand ischemia: use of 3- and 4-French systems

OBJECTIVES

The aim of this preliminary study is to report the results of catheter-based treatment for isolated distal upper extremity artery disease with CHI.

BACKGROUND

Critical hand ischemia (CHI) is a rare but potentially devastating condition.

METHODS

The study consisted of five critically ischemic hands (Rutherford category 4: 2, Rutherford category 5: 3) in four patients undergoing catheter intervention for isolated distal upper extremity artery disease between November 2007 and April 2009.

RESULTS

Balloon angioplasty via an antegrade brachial approach was performed with a 3Fr or 4Fr sheath to achieve the principal endpoint of the establishment of one straight-line flow to the palmar arch. All patients had end-stage renal disease requiring chronic hemodialysis. The target vessels were the ulnar artery in four cases, the radial artery in one, and the palmar arch in two. Four cases had a stenotic lesion and one had chronic total occlusion. Technical success was achieved in all cases without complications, and skin perfusion pressure of the hand improved significantly from 39 ± 20 to 52 ± 16 (P = 0.019) on the palmar side and from 40 ± 18 to 60 ± 29 on the dorsal side (P = 0.046). Clinical success was achieved in all cases during a mean follow-up period of 11 ± 8 (2-19) months.

CONCLUSIONS

Percutaneous angioplasty using contemporary dedicated devices could be a potentially useful option for CHI patients with isolated distal upper extremity artery disease.

Treatment of Dialysis Access-associated Steal Syndrome with the “Revision Using Distal Inflow” Technique

Purpose

Dialysis access-associated steal syndrome (DASS) is a common, serious complication of antecubital fossa (ACF) arteriovenous fistulas (AVFs). We describe our experience of the “revision using distal inflow” (RUDI) technique for the treatment of DASS and review the literature.

Methods

Patients underwent fistula ligation at the anastomosis with re-establishment of inflow via the proximal radial or ulnar arteries using a venous interposition graft or venous collateral. A retrospective analysis of outcomes of all patients undergoing this procedure at our center was carried out.

Results

Seven patients with autogenous ACF AVFs underwent the RUDI procedure, four under local anesthesia. Interposition vein grafts were used in five patients, and inflow was achieved through the proximal radial artery in four cases. The median post-operative rise in digital systolic blood pressure was 65.5 mmHg. Follow-up at 7–36 months found that three fistulas had failed (one at 8 months, two within days), two patients had died with patent fistulas, one patient was transplanted with a functional AVF, and the remaining patient continues to dialyze through the fistula. No patients developed DASS postoperatively and no further interventions were required to maintain patency.

Conclusions

Although RUDI was successful at treating DASS, a high rate of AVF failure was seen. With technical modifications and further experience, RUDI may become a valuable tool in the surgical armamentarium.

Current concepts in the pathophysiology and management of arteriovenous access-induced hand ischemia

The manifestations of hand ischemia because of an arteriovenous access can range from hand pain, tissue necrosis, and loss of the entire hand. Recent data have emphasized that multiple mechanisms (arterial steal, ie, retrograde flow, arterial stenosis, and arterial calcification) are responsible for inducing hand ischemia. Because any or a combination of the 3 mechanisms can lead to peripheral ischemia, distal hypoperfusion ischemic syndrome is a more appropriate term to denote hand ischemia. A detailed history, physical examination, and differential diagnosis form the initial step in the management of distal hypoperfusion ischemic syndrome. A complete arteriogram to evaluate the circulation of the extremity from the aortic arch to the palmar arch is essential. The choice of treatment modality should be based on this evaluation. In this article, we review the pathophysiology and present current strategies to ameliorate distal hypoperfusion ischemic syndrome.

Distal revascularisation with interval ligation (DRIL): an experience

INTRODUCTION

The global increase of chronic renal failure has resulted in a growing number of patients on haemodialysis using arteriovenous fistulas (AVFs). By virtue of their very function, AVFs at times shunt blood away from regions distally, resulting in an ischaemic steal syndrome. Distal revascularisation with interval ligation (DRIL) has been described as a procedure to treat symptomatic ischaemic steal. We present our experience in the management of this complication.

PATIENTS AND METHODS

Six patients with severe ischaemic steal were treated using a DRIL procedure between May 2004 and June 2007. There were three males and three females, all with elbow brachiocephalic AVFs. Symptoms ranged from severe rest pain to digital gangrene. Published results from international studies of 135 DRIL procedures were also reviewed.

RESULTS

Vascular access was maintained along with the elimination of ischaemic symptoms in the six patients using an ipsilateral reversed basilic vein graft. Interval ligation of the distal brachial artery was performed at the same time. All patients showed immediate and sustained clinical improvement of symptoms with a demonstrable increase in digital pulse oximetry.

CONCLUSIONS

DRIL is a beneficial treatment option that has proven successful at alleviating ischemic steal symptoms and preserving vascular access. This avoids placement of central lines, its associated risks, and the need to create an alternative sited fistula.

Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type

BACKGROUND

A small portion of haemodialysis patients develop hand ischaemia (HAIDI, haemodialysis access-induced distal ischaemia) in the presence of an arteriovenous access (AVA). It is unknown if the time of onset of ischaemia is related to the type of AVA. This review aims to investigate if a relationship is present between the type of AVA and the time of onset and intensity of HAIDI.

METHODS

Standard databases and reference lists of the pertinent literature were systematically searched. HAIDI was classified as 'acute' (<24 h after routine access construction), 'subacute' (within 1 month) or 'chronic' (>1 month). Location, type and follow-up of AVA were tabulated.

RESULTS

Twenty-one studies reporting on surgically or percutaneously corrected HAIDI patients (n = 464) fulfilled the inclusion criteria. Acute HAIDI strongly (88%) correlated with non-autogenous AVA. In contrast, chronic HAIDI was predominantly (91%) observed following autogenous AVA based on the cubital segment of the brachial artery. A simple clinical classification for chronic HAIDI guiding treatment strategies is proposed.

CONCLUSIONS

Hand ischaemia occurring early after routine access surgery is usually related to grafts and not to autogenous access construction. If patients have several risk factors for acute hand ischaemia (diabetes), nephrologists and vascular surgeons may choose an autogenous AVA. A disadvantage of an autogenous access is its association with chronic hand ischaemia, particularly if constructed with a brachial artery.

Complications of arteriovenous hemodialysis access: recognition and management

English language citations reporting complications of arteriovenous access for hemodialysis are critically reviewed and discussed. Venous hypertension, arterial steal syndrome, and high-output cardiac failure occur as a result of hemodynamic alterations potentiated by access flow. Uremic and diabetic neuropathies are common but may obfuscate recognition of potentially correctable problems such as compression or ischemic neuropathy. Mechanical complications include pseudoaneurysm, which may develop from a puncture hematoma, degeneration of the wall, or infection. Dysfunctional hemostasis, hemorrhage, noninfectious fluid collections, and access-related infections are, in part, manifestations of the adverse effects of uremia on the function of circulating hematologic elements. Impaired erythropoiesis is successfully managed with hormonal stimulation; perhaps, similar therapies can be devised to reverse platelet and leukocyte dysfunction and reduce bleeding and infectious complications.

Chronic hand ischemia treated with radial artery balloon angioplasty: case report

Although balloon angioplasty in heart and lower extremity vessels has been extensively studied and reported, little information exists regarding its use for digital ischemia in the hand. We report a case of successful balloon angioplasty of the distal radial artery to reverse present and prevent further digital tip cyanosis and necrosis.

Tratamento da síndrome do roubo devido a fístula arteriovenosa para hemodiálise em membro inferior por meio da técnica de ligadura arterial e revascularização distal (técnica de DRIL)

RESUMO A fístula arteriovenosa com bom fluxo sangüíneo é de fundamental importância para os pacientes portadores de insuficiência renal crônica em tratamento hemodialítico. Uma das complicações da fístula arteriovenosa é a síndrome do roubo, mas esta é de ocorrência incomum, e o seu tratamento está diretamente indicado quando há sintomas manifestos. Vários métodos foram propostos para sua correção nos membros superiores, sendo considerada a revascularização distal com ligadura arterial o procedimento de escolha. Neste relato de caso inédito, descreve-se o tratamento da síndrome do roubo de uma fístula arteriovenosa realizada em membro inferior, tratada com sucesso por meio da mesma técnica indicada para os membros superiores.

Dialysis shunt-associated steal syndrome (DASS) following brachial accesses: the value of fistula banding under blood flow control

BACKGROUND

Dialysis shunt-associated steal syndrome (DASS) is a rare complication of hemodialysis access (HA) which preferably occurs in brachial fistulas. Treatment options are discussed controversially. Aim of this study was to evaluate flow-controlled fistula banding.

MATERIALS AND METHODS

Patients treated between 2002 and 2006 were included in this prospective survey. According to a classification we established, patients were typed DASS I-III (I: short history, no dermal lesions; II: long history, skin lesions; III: long history, gangrene). Surgical therapy was HA banding including controlled reduction (about 50% of initial flow) of HA blood flow (patients type I and II). Patients with type III underwent closure of the HA.

RESULTS

In 15 patients with relevant DASS, blood-flow-controlled banding was performed. In ten patients (all type I), banding led to restitution of the hand function while preserving the HA. In five patients (all type II), banding was not successful; in two patients, closure of the HA was performed eventually. In five patients (type III), primary closure of the HA was performed. Four patients with DASS type II but only two with DASS type I had diabetes mellitus (p = 0.006).

CONCLUSIONS

Banding under blood flow control resulting in an approximately 50% reduction in the initial blood flow is an adequate therapeutic option in patients with brachial HA and type I-DASS. In type II-DASS, banding does not lead to satisfying results, more complex surgical options might be more successful. Diabetes is associated with poor HA outcome in case of DASS.