MILLER Banding Procedure for Treatment of Dialysis Access-Related Steal Syndrome, Pulmonary Hypertension, and Heart Failure

Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques

This systematic review and meta-analysis examine preventive operative techniques in high-risk patients undergoing surgery for hemodialysis access to mitigate the risk of Dialysis Access-Associated Steal Syndrome (DASS). Chronic kidney disease often leads to end-stage renal disease (ESRD), necessitating dialysis. Successful vascular access is crucial for efficient dialysis, but complications, such as DASS, pose significant challenges. DASS redirects arterial blood flow, affecting populations undergoing arteriovenous access surgery. This study aims to assess preventive strategies, including distal revascularization with interval ligation (DRIL) and extension techniques. A systematic search of PubMed, Cochrane Library, EMBASE, and Web of Science until 2022 identified 11 relevant studies. The inclusion criteria comprised non-pediatric hemodialysis patients reporting outcomes related to patency and complications. The data were analyzed using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Meta-analysis indicated a significant association between DASS and arteriovenous fistula (AVF) or arteriovenous graft (AVG) procedures. Radiocephalic AVF (RC-AVF) and distal endovascular AVF procedures were favored. Various interventions addressed venous narrowing, including simple plication and loop interposition. The Modified by Inserted Latex Link for Endovascular Repair (MILLER) technique, DRIL, Extension Technique, and Proximalization of Arterial Inflow (PAI) were assessed for arterial bypass graft and blood supply preservation. This study underscores the importance of individualized strategies in preventing DASS during hemodialysis access surgery. Prophylactic measures, such as the extension technique, show promise, while DRIL remains effective in treatment. Ongoing research is imperative for optimizing outcomes in this complex patient population.

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.