Proximalization of arterial inflow for treatment of hemodialysis access-induced distal ischemia

OBJECTIVE

Hemodialysis access-induced distal ischemia (HAIDI) is a known complication of hemodialysis (HD) access. Distal revascularization and interval ligation (DRIL) is the preferred treatment for HAIDI by many surgeons. Proximalization of arterial inflow (PAI) is a promising alternative technique that, unlike DRIL, preserves the native arterial inflow. The purpose of this study is to report our experience with PAI on a series of 64 patients.

METHODS

This is a single-center, retrospective cohort study of patients with both arteriovenous (AV) fistulas and grafts who underwent PAI for HAIDI from 2017 to 2023. A 4 × 7 tapered polytetrafluoroethylene (PTFE) graft was used to connect HD access inflow to the axillary artery in the majority of cases. The primary outcome of the study is resolution of HAIDI (complete, partial, or no resolution). Secondary outcomes include functional patency (primary and secondary) and 30-day complications following PAI.

RESULTS

Of the 71 patients identified to have had PAI between May 2017 to August 2023, seven were lost to follow-up. In total, 64 patients were included, with an average age of 65 years (standard deviation, 15 years), 59.4% (38/64) female, and 37.5% (24/64) African American. The study population was notable for numerous comorbid conditions including 95.3% (61/64) hypertension; 50% (32/64) coronary artery disease; 79.7% (51/64) diabetes; and 43.8% (28/64) smoking history. Following PAI intervention for HAIDI, 55 of 64 patients (85.9%) experienced complete resolution of ischemic symptoms; five of 64 patients (7.8%) had partial resolution; two of 64 patients (3.1%) had no resolution, and two of 64 patients (3.1%) had unknown resolution. Primary patency at 1, 12, and 24 months was 94%, 81%, and 71%, respectively. Secondary patency at 1, 12, and 24 months was 97%, 87%, and 84%, respectively. The 30-day complication rate was 10.9% (7/64), with five of 64 (7.8%) thromboses, one of 64 (1.6%) thrombosis and infection, and one of 64 (1.6%) upper extremity swelling secondary to central venous stenosis (resolved with angioplasty of central venous system). Failure rate due to thrombosis at 12 and 24 months was 14% (9/64) and 15.6% (10/64), respectively.

CONCLUSIONS

Our study, the largest case series of PAI to date, demonstrates that PAI is a reliable option for HAIDI intervention and has comparable safety and efficacy results to DRIL, despite the use of a synthetic graft. Furthermore, PAI has the added benefit of maintaining the native arterial pathway. Further investigation of PAI is warranted as a promising alternative to DRIL for HAIDI management.

Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution's 20-Year Experience

PURPOSE

To determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS).

MATERIALS AND METHODS

A retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions.

RESULTS

Technical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups.

CONCLUSIONS

In this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.

Contemporary outcomes of distal radial artery ligation for access related hand ischemia

OBJECTIVES

Access related hand ischemia (ARHI) is a rare albeit morbid complication of hemodialysis access creation. Distal radial artery ligation (DRAL) has been described as a strategy to improve perfusion to the hand while maintaining the access. The objective of this study was to report longitudinal outcomes of DRAL for ARHI.

METHODS

Retrospective cohort study (2015-2021) of all patients who underwent DRAL for ARHI at a tertiary care vascular center. Subjects were identified using the Mass General Brigham clinical data warehouse and data collection was supplemented with chart adjudication. Outcomes captured included 30-day complications and improvement in ARHI-related symptoms at 1 year.

RESULTS

Thirty-one patients were included. Mean (SD) age was 59.9 (14.5) and 67.7% were male. Wrist radial-cephalic (74.2%) and proximal radial-cephalic (9.7%) configurations were most common. ARHI severity was: 9.7% stage 1 (retrograde flow without symptoms); 38.7% stage 2 (pain during exercise or dialysis); 41.9% stage 3 (pain at rest); and 9.7% stage 4 (tissue loss). High flow was present in 35.5% of patients at baseline with median (IQR) flow of 1670 ml/min (1478-1954). After DRAL, median (IQR) flow reduction in the high flow group was 953 ml/min (645-993); concurrent precision banding was performed in 29% to reduce flow. The 30-day risk of complication was 3.2% (n = 1 access thrombosis). During follow-up, 82.1% showed improvement in symptoms and 3.6% of patients needed an additional procedure for ARHI. Carpal tunnel surgery was required for improvement in 7.1% of patients and was suspected as the culprit of symptoms in 7.1%.

CONCLUSION

Distal radial artery ligation for ARHI is safe and can improve ischemic symptoms in most patients while salvaging access function. Precision banding can serve as a useful adjunct in high flow accesses. Carpal tunnel syndrome should be considered as part of the differential diagnosis of hand pain in this population.

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.

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.

Proximalization through one incision of a wrist arteriovenous fistula and distal revascularization with interval ligation

In the setting of ischemic steal syndrome with tissue loss, patients with radiocephalic fistulas have limited options to preserve their conduit and treat their ischemic symptoms. To address this, we have proposed the technique of proximalization through one incision of a wrist arteriovenous fistula (POWR) with distal revascularization with interval ligation (DRIL) procedure. In the present retrospective, single-center, case series, we evaluated the outcomes of three patients with radiocephalic fistulas who had undergone POWR DRIL from 2017 to 2021. Their ischemic symptoms were monitored for regression. All three patients showed signs of regressing ischemia. The POWR DRIL represents an efficient procedure to address tissue loss and preserve the autogenous conduit.

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.

Ultrasound evaluation of dialysis access-related distal ischaemia

Dialysis access-related distal ischaemia is a rare yet potentially rather risky complication of haemodialysis angioaccess. Timely diagnosis is crucial to target both the goals of the access team: first of all to preserve the function of the hand ideally along with angioaccess patency. Unfortunately for some patients, urgent access ligation and central vein catheter insertion would be needed to save the hand. After a first clinical examination to determine the diagnostic suspicion, the ultrasound evaluation would provide nearly all the needed information to confirm the diagnosis and to determine the most appropriate procedure to rescue the patient from distal ischaemia. In some cases, photoplethysmography would help in the differential diagnosis of other non-ischaemic causes of similar signs and symptoms. Angiography would complete the preoperative evaluation for some.Dialysis access-related distal ischaemia would be briefly reviewed, and a deep description of the ultrasound examination tools and findings would be provided for a tailored therapeutic approach.

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.

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.

Distal radial artery ligation for treatment of steal syndrome associated with radiocephalic arteriovenous fistula

We present a case of dialysis associated steal syndrome in a hemodialysis patient with left radiocephalic arteriovenous fistula that caused him severe rest pain. Angiography showed retrograde flow from the ulnar artery to the distal radial artery through a hypertrophied palmar arch. The problem was solved by surgical ligation of the distal radial artery leading to complete relief of patient symptoms without any notable complications.

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.

Avoiding hemodialysis access-induced distal ischemia

Timely creation and maintenance of a safe and reliable vascular access is essential for hemodialysis patients with end-stage renal disease. Hemodialysis access-induced distal ischemia (HAIDI) is a recognized complication of arteriovenous fistulas and grafts that may result in serious or even devastating consequences. Avoiding such complications is clearly preferred over treatment of HAIDI once established. Proper recognition of patients at increased risk of HAIDI includes careful pre-operative evaluation of the patient's medical and surgical history along with physical examination and imaging to determine a plan for creating a functional permanent access while minimizing the risk of distal ischemia. Our aim is to review identifying characteristics of individuals at risk of HAIDI and provide recommendations regarding pre-operative assessment. Vascular access options and techniques are suggested for establishing a functional vascular access without distal ischemia for such patients.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

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.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

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.

Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies

Distal hypoperfusion ischemic syndrome (DHIS), commonly referred to as hand ischemia or “steal” after dialysis access placement, occurs in 5–10% of cases when the brachial artery is used, or 10 times that of wrist arteriovenous fistulas (AVFs) using the radial artery. It is typically seen in elderly women with diabetes, and may carry severe morbidity including tissue or limb loss if not recognized and treated. Three distinct etiologies include (1) blood flow restriction to the hand from arterial occlusive disease either proximal or distal to the AV access anastomosis, (2) excess blood flow through the AV fistula conduit (true steal), and (3) lack of vascular (arterial) adaptation or collateral flow reserve (ie atherosclerosis) to the increased flow demand from the AV conduit. These three causes of steal may occur alone or in concert. The diagnosis of steal is based on an accurate history and physical examination and confirmed with tests including an arteriogram, duplex Doppler ultrasound (DDU) evaluation with finger pressures and waveform analysis. Treatment of steal includes observation of developing symptoms in mild cases. Balloon angioplasty is the appropriate intervention for an arterial stenosis. At least three distinct surgical corrective procedures exist to counteract the pathophysiology of steal. The ultimate treatment strategy depends on severity of symptoms, the extent of patient co-morbidity, and the local dialysis access technical team support and skills available.

Aggressive Approach to Salvage Non-Maturing Arteriovenous Fistulae: A Retrospective Study with follow-up

Purpose

To establish a standardized approach for the maturation of non-maturing arteriovenous fistulae.

Methods

consecutive patients (n=122) with non-maturing fistulae presented to our outpatient vascular access center for percutaneous interventions to assist in maturation. The techniques used included flow rerouting, competing branch vein elimination, staged balloon angioplasty, and limited controlled extravasation.

Results

Successful fistula maturations were achieved in 118/122 patients. Fistulae were divided into two classes according to initial vessel size: class 1 (6.0–8.0 mm diameter, >6 mm deep) and class 2 (2.0–5.0 mm diameter) fistulae were evaluated for differences in technical procedures and clinically successful fistula maturation. Class 1 and class 2 fistulae were evaluated for mean number of procedures to maturation (1.6 and 2.6, respectively), and time to maturation (5 and 7 weeks, respectively). Follow-up for 109 of the initial 118 patients was achieved (mean=24 months, range=0.25–60 months). Class 1 and class 2 fistulae had primary patencies of 17 and 39% at 6 months; and secondary patencies of 72 and 77% at 12 months, 53 and 61% at 24 months, and 42 and 32% at 36 months, respectively. Primary and secondary patencies (Mann-Whitney test, p=0.44 and p=0.38, respectively) of class 1 and class 2 fistulae did not differ significantly, and secondary patencies were comparable to other fistula salvage studies.

Conclusion

Fistula salvage attempts should not be limited by factors such as a diffusely small diameter or an inaccessibly deep position.

The sleeve method for creation of radiocephalic arteriovenous fistulas in patients with calcified vessels

INTRODUCTION

Creation of an arteriovenous fistula (AVF) in patients with advanced atherosclerotic changes of the artery is often a challenge for the physician due to difficulties in suturing the vein to the side of the frangible artery. The sleeve technique relies on advancing the end of the artery into the lumen of the vein and protecting the anastomosis by adventitial sutures.

MATERIAL AND METHODS

The sleeve technique was performed in 23 patients with chronic kidney disease stage IV and V and included hemodialysis patients. Their mean age was 60.8 ± 14.8 years and hemodialysis treatment time 49.8 ± 40.2 months. The most frequent causes of chronic kidney disease are ischemic nephropathy (43%, n = 10) and type l diabetes (21%, n = 5). Only patients with extremely advanced atherosclerotic were recruited and analyzed.

RESULTS

The primary patency rate was 67%, 59%, 44% and 28% at 6, 12, 24, and 36 months, respectively. The secondary patency rate was 67%, 61%, 50% and 37% at 6, 12, 24, and 36 months, respectively. In three patients the AVF failed directly after the operation. Delayed fistula failure occurred in seven patients. The overall success in the creation of a functioning fistula was achieved in 15 of the 23 patients (65%). No serious complications were observed.

CONCLUSIONS

In patients with calcified atherosclerotic plaques, which constitute a barrier or make it difficult to suture the vein to the side of the artery, the sleeve method may be considered as an alternative before abandoning the creation of a fistula on the forearm. The technique is much simpler than the standard end-to-side or side-to-side anastomosis.

Arteriovenous access banding revisited

Purpose

The aim of this study is to validate the current applicability of arteriovenous access banding in high flow access (HFA) and/or haemodialysis access-induced distal ischaemia (HAIDI).

Methods

This retrospective study was conducted at the GEV (Grupo de Estudos Vasculares) vascular access centre. The clinical records of consecutive patients undergoing banding for HAIDI and HFA symptoms, between June 2011 and January 2015, were reviewed until April 2015. All vascular access patients’ consultation records and surgical notes were reviewed. We analysed and compared patients’ age, gender, comorbidities, symptoms and intraoperative ultrasound control. We defined technical failure as recurrence of symptoms, requiring new banding. Excessive banding, access thrombosis, rupture and false aneurysm development were registered as complications. Primary clinical success was defined as improvement of symptoms or effective flow reduction after banding, with no need for reintervention. If one reintervention was necessary, we have defined it as secondary clinical success.

Results

Overall, 119 patients underwent banding: 64 (54%) with HAIDI and 55 (46%) with HFA. The HAIDI group was significantly older (65 ± 13 years compared with 56 ± 22 years, p = 0.001) and had significantly greater number of patients with diabetes (56% vs 24%, p = 0.004). Primary success was achieved in 85 patients (71.4%) and the secondary success rate was 84.9%. Older age (p = 0.016) and intraoperative ultrasound control (p = 0.012) were significantly associated with primary success.

Conclusions

Our results do not corroborate the high incidence of thrombosis previously reported as associated with AV access banding and suggest that ultrasound control is crucial for preventing technical failure. The procedure was effective on both compared groups.

Arteriovenous access ischemic steal (AVAIS) in haemodialysis: a consensus from the Charing Cross Vascular Access Masterclass 2016

Arteriovenous access ischaemic steal (AVAIS) is a serious and not infrequent complication of vascular access. Pathophysiology is key to diagnosis, investigation and management. Ischaemia distal to an AV access is due to multiple factors. Clinical steal is not simply blood diversion but pressure changes within the adapted vasculature with distal hypoperfusion and resultant poor perfusion pressures in the distal extremity. Reversal of flow within the artery distal to the AV access may be seen but this is not associated with ischaemia in most cases.

Terminology is varied and it is suggested that arteriovenous access ischemic steal (AVAIS) is the preferred term. In all cases AVAIS should be carefully classified on clinical symptoms as these determine management options and allow standardisation for studies.

Diabetes and peripheral arterial occlusive disease are risk factors but a ‘high risk patient’ profile is not clear and definitive vascular access should not be automatically avoided in these patient groups.

Multiple treatment modalities have been described and their use should be directed by appropriate assessment, investigation and treatment of the underlying pathophysiology. Comparison of treatment options is difficult as published studies are heavily biased. Whilst no single technique is suitable for all cases of AVAIS there are some that suit particular scenarios and mild AVAIS may benefit from observation whilst more severe steal mandates surgical intervention.

Access-related hand ischemia and the Hemodialysis Fistula Maturation Study

OBJECTIVE

Access-related hand ischemia (ARHI) is a major complication after hemodialysis access construction. This study was designed to prospectively describe its incidence, predictors, interventions, and associated access maturation.

METHODS

The Hemodialysis Fistula Maturation Study is a multicenter prospective cohort study designed to identify predictors of autogenous arteriovenous access (arteriovenous fistula [AVF]) maturation. Symptoms and interventions for ARHI were documented, and participants who received interventions for ARHI were compared with other participants using a nested case-control design. Associations of ARHI with clinical, ultrasound, vascular function, and vein histologic variables were each individually evaluated using conditional logistic regression; the association with maturation was assessed by relative risk, Pearson χ(2) test, and multiple logistic regression.

RESULTS

The study cohort included 602 participants with median follow-up of 2.1 years (10th-90th percentiles, 0.7-3.5 years). Mean age was 55.1 ± 13.4 (standard deviation) years; the majority were male (70%), white (47%), diabetic (59%), smokers (55%), and on dialysis (64%) and underwent an upper arm AVF (76%). Symptoms of ARHI occurred in 45 (7%) participants, and intervention was required in 26 (4%). Interventions included distal revascularization with interval ligation (13), ligation (7), banding (4), revision using distal inflow (1), and proximalization of arterial inflow (1). Interventions were performed ≤7 days after AVF creation in 4 participants (15%), between 8 and 30 days in 6 (23%), and >30 days in 16 (63%). Female gender (odds ratio, 3.17; 95% confidence interval, 1.27-7.91; P = .013), diabetes (13.62 [1.81-102.4]; P = .011), coronary artery disease (2.60 [1.03-6.58]; P = .044), higher preoperative venous capacitance (per %/10 mm Hg, 2.76 [1.07-6.52]; P = .021), and maximum venous outflow slope (per [mL/100 mL/min]/10 mm Hg, 1.13 [1.03-1.25]; P = .011) were significantly associated with interventions; a lower carotid-femoral pulse wave velocity and the outflow vein diameter in the early postoperative period (days 0-3) approached significance (P < .10). Intervention for ARHI was not associated with AVF maturation failure (unadjusted risk ratio, 1.18 [0.69-2.04], P = .56; adjusted odds ratio, 0.97 [0.41-2.31], P = .95).

CONCLUSIONS

Remedial intervention for ARHI after AVF construction is uncommon. Diabetes, female gender, capacitant outflow veins, and coronary artery disease are all associated with an increased risk of intervention. These higher risk patients should be counseled preoperatively, their operative plans should be designed to reduce the risk of hand ischemia, and they should be observed closely.

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.

The MILLER banding procedure as a treatment alternative for dialysis access steal syndrome: a single institutional experience

OBJECTIVE

To describe a single institutional experience with minimally invasive limited ligation endoluminal-assisted revision (MILLER) for treatment of dialysis access steal syndrome (DASS).

MATERIALS AND METHODS

Twenty patients were retrospectively identified that underwent 30 MILLER band procedures for DASS at our institution from March 2010 to December 2014. Technical success was defined by successful creation of MILLER band with preservation of flow for hemodialysis. Clinical success was defined as complete resolution of signs and symptoms with preservation of dialysis access in a 1-month postprocedural period. Primary MILLER band patency, postintervention-assisted primary access patency, and postprocedure secondary access patency are reported.

RESULTS

Technical success was achieved in all patients. Clinical success was achieved in 75% of patients after one banding procedure and in 95% of patients after two banding procedures. One patient experienced access thrombosis following the initial banding procedure which was subsequently treated and did not lead to loss of access. MILLER band patency was 83% at 1 month and 77% at 6 months. Postintervention-assisted primary patency was 95%, 93%, and 92% at 3 months, 6 months, and 1 year, respectively. Postintervention secondary patency was 86%, 68%, and 59% at 3 months, 6 months, and 1 year, respectively.

CONCLUSIONS

MILLER banding offers a less-invasive alternative to surgical therapy that appears to be safe and permits preservation of dialysis access.

Intervention for Access-Induced Ischemia: Which Option is the Best?

Introduction

Access-induced ischemia is a rare but important surgical complication with potentially devastating long-term results. The question remains which therapeutic option is the best for the different forms of ischemia.

Method

A review of the literature concerning access-induced ischemia (classification, treatment) was performed; furthermore, our own experience of more than 300 cases with ischemia was discussed.

Results

There are four different stages of dialysis access-induced ischemia syndrome (DAIIS) that need adequate treatment: stage I conservatively, stage II fistula banding, stage III proximalization operation or distal revascularization interval ligation and stage IV closure of the access.

Discussion

According to the many publications and to our own experience, there are good therapeutic options for many of the patients with DAIIS. However, in case of extended lesions/gangrene, closure of the access should be discussed in time before major amputation becomes necessary.

Long-term preservation of native arteriovenous dialysis fistulas

Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.

Radiocephalic fistula: review and update

Since initially described in 1966, radiocephalic fistula or Brescia-Cimino fistula is one of the most commonly performed fistulas in the world of arteriovenous access. The indications for insertion include, but are not limited to, hemodialysis. Although this is a frequently performed procedure, the primary and secondary patency rates and predictors of failure are not well defined. The review of this topic is difficult because of the diversity in reporting and the absence of consensus between series. Following the current published recommendations by the Society of Vascular Surgery regarding standardization of terminology to facilitate meaningful comparison between the diversity of published data, this review is an attempt to summarize and highlight the relevant information with regard to primary patency, secondary patency, and predictors of failure of radiocephalic fistula using the available English literature.

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.

Sharp Needle Recanalization for Salvaging Hemodialysis Accesses with Chronically Occluded Peripheral Outflow

Purpose

To assess the effectiveness of sharp needle recanalization (SNR) for treatment of chronically occluded venous outflow in hemodialysis access.

Methods

A retrospective analysis of patient records from January 2006 to March 2010 was conducted. Forty-four hemodialysis patients (31 fistulas, 13 grafts) were referred for arm swelling (18%), excessive bleeding after dialysis (29%), and thrombosis (53%). All patients had chronic occlusion of the outflow vein which failed conventional recanalization techniques. A new outflow pathway was established by advancing a 21g needle and dilating the subcutaneous tract to bridge the fistula body to a juxtaposed patent vein. If necessary, uncovered or covered stents were utilized to maintain patency of the newly formed subcutaneous tract.

Results

Forty-four patients underwent 45 SNR procedures, with restoration of normal function and complete relief of symptoms in 40 (91%) patients. The average tract length was 15 mm (range, 1 to 32) and the average dilatation diameter was 8 mm. During the initial SNR procedure, bare metal (n=21) or covered (n=5) stents were inserted in 26 patients. The average follow-up was 18.4 months (range, 0.2 to 48 months). No major complications were observed with the procedure. At 12 months, the primary access, primary tract, and secondary access patencies were 10%, 51%, and 92%, respectively. Percutaneous thrombectomy procedures were performed at a rate of 1.16 per access-year and the number of interventions within the tract was 0.94 per access-year.

Conclusions

Sharp needle recanalization is an effective percutaneous treatment for restoring function to hemodialysis accesses with chronically occluded venous outflow pathways.

Simple and Durable Resolution of Steal Syndrome by Conversion of Brachial Artery Arteriovenous Fistulas to Proximal Radial Artery Inflow

Dialysis associated steal syndrome (DASS) is relatively uncommon but constitutes a serious risk for patients undergoing vascular access operations. We report two patients with DASS where brachial artery vascular access inflow was revised to the proximal radial artery for arteriovenous fistula (AVF) inflow. DASS was resolved in both patients with the permanent resolution of symptoms, in addition to the healing of ulcerations and ischemia. Both AVFs were immediately functional and durable.