Transcatheter coil embolization for steal syndrome in patients with hemodialysis access

Dialysis Access-Associated Steal Syndrome and Management

Dialysis-associated steal syndrome (DASS) occurs in 1-8% of hemodialysis patients with arteriovenous (AV) access. Major risk factors include use of the brachial artery for access creation, female sex, diabetes, and age > 60 years. DASS carries severe patient morbidity including tissue or limb loss if not recognized and managed promptly, as well as increased mortality. Diagnosis of DASS requires a directed history and physical exam supported by non-invasive testing. Prior to definitive therapy, detailed arteriography, fistulography, and flow measurements are performed to delineate underlying etiologies and guide management. To optimize success, DASS treatment should be individualized according to access location, underlying vascular disease, flow dynamics, and provider expertise. Possible causes of DASS include extremity inflow or outflow arterial occlusive disease, high AV access flow rate, and reversal of distal extremity arterial blood flow; DASS may also exist without any of the prior features. Depending on the DASS etiology, various endovascular and/or surgical interventions should be considered. Regardless, in the majority of patients presenting with DASS, access preservation can be achieved.

Endovascular Embolization in Problematic Hemodialysis Arteriovenous Fistulas: A Nonsurgical Technique

Introduction:

In the past, surgical techniques were considered gold standard practice for obliterating the accessory veins, reducing the flow across the high flowing arteriovenous fistulas (AVFs), or for closing the problematic hemodialysis AVFs. However, recently endovascular embolization has emerged as a safe and cost-effective alternative to these surgical techniques. In this study, technical and clinical success, and safety of endovascular embolization have been evaluated for accessory vein obliteration, flow reduction, and fistula closure in problematic AVFs using various embolizing agents.

Methods:

This is a retrospective study of patients with problematic hemodialysis AVFs, who underwent endovascular embolization for accessory vein obliteration, flow reduction, and AVF closure at our center from February 2017 to January 2019 with various embolic agents like vascular plugs (VP), thrombin, coils, and glue. Follow-up was done at 1 week, 3 months, 6 months, and annually thereafter.

Results:

In this study 30 patients with problematic hemodialysis AVFs [Left brachiocephalic fistula (BCF) (n = 22), right BCF (n = 4), and left radiocephalic fistula (RCF) (n = 4)], underwent endovascular embolization for accessory vein obliteration (n = 6), flow reduction (n = 3), and AVF closure (n = 21). Of the 6 patients undergoing embolization for obliteration of accessory collateral, 4 patients had nonmaturing AVFs and 2 patients had symptoms of venous hypertension (VH). Post embolization, all 4 AVFs matured over a month and symptoms of VH completely resolved within a week. Three patients who underwent embolization for flow reduction had patent AVF (on doppler) post procedure and they achieved adequate flow during dialysis with complete resolution of symptoms of VH. Out of 21 patients, who underwent endovascular closure, complete AVF thrombosis was seen in 18 patients only with the use of VP, while 4 patients required additional procedure to achieve complete thrombosis of AVF.

Conclusion:

Endovascular embolization in problematic hemodialysis AVF is a safe and cost-effective alternative to open surgical methods and vascular plug could be embolic agent of choice for AVF closure.

Coil Embolization of Tributaries of Brachiocephalic Fistula is Effective in the Management of Vascular Steal

BACKGROUND

To determine if an aggressive approach to occlude all or majority of the tributaries of the cephalic vein is effective in eliminating signs and symptoms of vascular steal in patients with brachiocephalic fistula.

METHODS

Retrospective chart review over a 15-month period of all patients managed with coil embolization of tributaries of brachiocephalic fistulae.

RESULTS

A total of 19 patients (11 females, age 65 ± 9.7 years), presented with signs and symptoms of vascular steal. All patients had a brachiocephalic fistula with a 6.3 month average fistula age. Overall, a total of 111 coils were used to occlude 42 tributaries. Two patients had concomitant surgical ligation of 3 tributaries. Postoperative pain at the site of coiled tributaries was reported by two patients. A single patient suffered a major postprocedure complication (delayed hypotension), requiring hospital admission. All but one patient had significant improvement in symptoms of vascular steal postintervention.

CONCLUSIONS

An aggressive approach to coil embolization of all major tributaries of a brachiocephalic fistula is effective in eliminating signs and symptoms of vascular steal.

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.

Brescia-Cimino AV Fistula Complicated by Steal Syndrome

The Brescia-Cimino AV fistula is most commonly performed and rarely associated with steal syndrome. A case is presented with details regarding its correction.

Combined Endovascular Treatment with Distal Radial Artery Coil Embolization and Angioplasty in Steal Syndrome Associated with Forearm Dialysis Fistula

PURPOSE

The present study was performed to define the results of the endovascular treatment with angioplasty and distal radial artery embolization in ischemic steal syndrome associated with forearm arteriovenous accesses.

METHOD

The cases referred to our interventional radiology unit with symptoms and physical examination findings suggestive of ischemic steal syndrome were retrospectively evaluated first by Doppler ultrasonography, and then by angiography. Cases with proximal artery stenosis were applied angioplasty, and those with steal syndrome underwent coil embolization to distal radial artery.

RESULTS

Of 589 patients who underwent endovascular intervention for dialysis arteriovenous fistulae (AVF)-associated problems, 6 (1.01 %) (5 female, 1 males; mean age 62 (range 41-78) with forearm fistula underwent combined endovascular treatment for steal syndrome. In addition to steal phenomenon, there were stenosis and/or occlusion in proximal radial and/or ulnar artery in 6 patients concurrently. Embolization of distal radial artery and angioplasty to proximal arterial stenoses were performed in all patients. Ischemic symptoms were eliminated in all patients and the AVF were in use at the time of study. In one patient, ischemic symptoms recurring 6 months later were alleviated by repeat angioplasty of ulnar artery.

CONCLUSION

In palmar arch steal syndrome affecting forearm fistulae, combined distal radial embolization and angioplasty is also an effective treatment method in the presence of proximal radial and ulnar arterial stenoses and occlusions.

Coil Embolization as a Treatment Alternative for Dialysis-Associated Steal Syndrome

Steal syndrome is a rare but serious complication of arteriovenous fistulas (AVF) created as well as the angioplasty technique used for its maturation and can have severe consequences if left untreated. Standard treatment options generally lead to loss of fistula access, although newer practices such as coil embolization are being utilized to conserve the AVF. Here we illustrate a case of a 65-year-old man with end-stage renal disease on dialysis, who had a Brescia-Cimino (radiocephalic) AV fistula created and subsequently underwent balloon-assisted maturation for an underdeveloped fistula. One month later, the patient presented with a cold thumb and index finger along with parasthesias in those digits and was treated with coil embolization of the distal radial artery while leaving the AVF functional. Steal syndrome and the novel treatment option of coil embolization are reviewed here.

Side branch ligation for haemodialysis-access-induced distal ischaemia

OBJECTIVE

Chronic hand ischaemia is occasionally observed in haemodialysis patients with a brachiocephalic fistula using the Gracz technique. Open venous side branches of the access may contribute to lower peripheral perfusion pressures. This study reports on the effects of access side branch ligation (SBL) on ischaemia in patients with haemodialysis access induced distal ischaemia (HAIDI).

DESIGN, MATERIALS AND METHODS

Hand ischaemia was quantified using a published questionnaire (HIQ, minimal 0 points: no ischaemia, maximal 500: excruciating ischaemia). Finger pressures (P(dig), mmHg), digital brachial index (DBI) and access flow were measured before and after SBL.

RESULTS

Twenty-two patients were operated for grade 2-4 HAIDI during 7 years, and 12 underwent SBL (as single procedure n = 5, preceeding banding/DRIL n = 7). Hand ischaemia was attenuated after SBL only (n = 5, HIQ 216 ± 39 vs. 73 ± 26, P = 0.04). A 25% increase was observed in both P(dig) (n = 12, before SBL: 57 ± 8 mmHg, after: 72 ± 8 mmHg, P = 0.012) and DBI (before SBL: 0.49 ± 0.06, after: 0.61 ± 0.04, P = 0.006). Access flow did not change. All patients successfully resumed dialysis.

CONCLUSION

SBL may be effective as single or adjunctive surgical procedure in the treatment of HAIDI in the presence of a Gracz fistula.

Predictors of steal syndrome in hemodialysis patients

Steal syndrome is a feared complication of dialysis vascular access in a population becoming older and frailer. The aim of this study was to determine the predictor factors of steal syndrome. All proximal arteriovenous fistulas (AVFs), patent at day 30, inserted between January 2008 and December 2009 were studied. Data on age, gender, diabetes mellitus (DM) status, presence of coronary or peripheral artery disease, date of initiation of renal replacement therapy, date of access construction, localization, type of anastomosis, previous interventions, and outcome for AVF and patients were analyzed. There were 324 AVFs placed into 309 individual patients. The mean age was 66.7 ± 15.3 years, and the majority (53.7%) of the patients was male. Mean follow-up of all 324 fistulas was 18.6 ± 8.5 months. During follow-up, steal syndrome occurred in 26 (8%) of the AVFs. Univariate analysis revealed correlations between steal syndrome and DM (P = 0.002), brachiomedian fistulas (P = 0.016), and side-to-side (STS) anastomosis (P = 0.003). However, in multivariate analysis, the presence of DM, STS anastomosis, and female gender were found to be the independent risk factors. The strongest predictive factor was DM (odds ratio: 6.7; 95% confidence interval: 2.5-17.9). Being diabetic is the factor most predictive of having steal syndrome. In diabetic women, with a proximal access, it seems preferable to construct fistulas with end-to-side anastomosis to minimize the risk.

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.