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Ravindhran B, Totty JP, Sidapra M, Lathan R, Carradice D, Chetter IC, Smith GE. Long term outcomes of 'Christmas Tree' banding for haemodialysis access induced distal ischemia: A 13-year experience. J Vasc Access 2024; 25:863-871. [PMID: 36474333 DOI: 10.1177/11297298221141497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND The reduction in distal arterial flow following arteriovenous fistula (AVF) creation can cause a perfusion deficit known as haemodialysis access induced distal ischemia (HAIDI). Various techniques have been advocated to treat this difficult problem with varying success. We present the long-term outcomes following a novel banding technique. METHODS 46 patients in this cohort from 2008 to 2021 underwent a novel banding procedure using a Dacron™ patch shaped with one slit-end and saw-tooth edges (resulting in a 'Christmas-tree' pattern) to provide a ratchet mechanism to progressively constrict the fistula outflow. Real-time finger perfusion pressure monitoring allowed an accurate reduction in AVF flow whilst increasing distal arterial perfusion pressure. Baseline characteristic were recorded and Kaplan-Meier survival curves were obtained to calculate the post-intervention primary, assisted primary and secondary patency. RESULTS 29 patients presented with rest pain and 11 presented with tissue loss due to distal ischemia. The post-intervention primary access patency was 100%, 98%, 78% and 61% at 30, 60 and 180 days and 1 year respectively. Complete resolution of symptoms was achieved in 74% (n = 34) of patients and a partial response needing no further intervention was achieved in 11% (n = 5) of patients. A Youden index calculation suggested that digital pressures of 41 mm Hg or lower in an open AVF were highly sensitive for symptomatic hand ischemia whereas pressures greater than 65 mm Hg ruled out distal ischemia. CONCLUSION 'Christmas-tree' banding with on table finger systolic pressures is not only an efficacious and durable method for treating HAIDI but also preserves fistula patency.
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Affiliation(s)
| | - Joshua P Totty
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Misha Sidapra
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Ross Lathan
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
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Soo Hoo AJ, Scully RE, Sharma G, Patterson S, Walsh J, Voiculescu A, Belkin M, Menard M, Keith Ozaki C, Hentschel DM. Contemporary outcomes of precision banding for high flow hemodialysis access. J Vasc Access 2023; 24:1260-1267. [PMID: 35139679 DOI: 10.1177/11297298221076581] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE High-flow hemodialysis accesses are a well-recognized source of patient morbidity. Among available management strategies inflow constriction based on real-time physiologic flow monitoring offers a technically straightforward data-driven approach with potentially low morbidity. Despite the benefits offered by this approach, large contemporary series are lacking. METHODS A retrospective review of a prospectively maintained clinical database was undertaken to capture patients undergoing precision banding within a signal tertiary care institution between 2010 and 2019. Multivariable logistic regression modeling of thrombosis within 30 days and re-banding within 1 year were performed. RESULTS In total, 297 patients underwent banding during the study period for a total number of 398 encounters. Median [IQR] follow-up was 157 [52-373] days. Most accesses were upper arm with brachial artery inflow (84%) and half of the banding procedures were performed for flow imbalance based on exam, duplex, or fistulogram. Median flow rate reduction was 58%. The 30-day thrombosis rate after banding was 15 of 397 (3.8%) with a median time to event of 5.5 days (2-102). The re-banding rate within a year was 54 of 398 (14%) with a median time to re-banding of 134 days [56-224]. Multivariate logistic regression analysis using a univariate screen did not identify any predictors of 30-day thrombosis. Having a forearm radial-cephalic AVF compared to all other access types was protective against need for rebanding at 1 year (OR 0.12 95% CI 0.02-0.92, p = 0.04), as was flow imbalance as the indication for banding (OR 0.43 95% 0.23-0.79, p = 0.006). CONCLUSIONS Precision banding offers an effective, low-morbidity approach for high-flow hemodialysis accesses. Early thrombosis is a rare event after precision banding, although in the long term, one in four patients will require re-banding to maintain control of flow volumes.
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Affiliation(s)
- Andrew J Soo Hoo
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca E Scully
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Gaurav Sharma
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Suzannah Patterson
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Adina Voiculescu
- Interventional Nephrology, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Dirk M Hentschel
- Interventional Nephrology, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Alqahtani SS, Aljaber FK, Alsuwailem BY, AlMashouq YA, AlHarbi BG, Elawad AM. Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques. Cureus 2023; 15:e49612. [PMID: 38161832 PMCID: PMC10755340 DOI: 10.7759/cureus.49612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
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.
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Affiliation(s)
- Saeed S Alqahtani
- Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, DEU
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Fahad K Aljaber
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Bader Y Alsuwailem
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
- Vascular Surgery, King Fahad Medical City, Riyadh, SAU
| | | | - Bander G AlHarbi
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
- Vascular Surgery, Samsung Medical Center, Seoul, KOR
| | - AlSayed M Elawad
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
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Stoecker JB, Li X, Clark TWI, Mantell MP, Trerotola SO, Vance AZ. Dialysis Access-Associated Steal Syndrome and Management. Cardiovasc Intervent Radiol 2023; 46:1168-1181. [PMID: 37225970 DOI: 10.1007/s00270-023-03462-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
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.
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Affiliation(s)
- Jordan B Stoecker
- Division of Vascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Xin Li
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy W I Clark
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Penn Presbyterian Medical Center, 4 Wright Saunders Building, 51 N. 39th Street, Philadelphia, PA, 19104, USA
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott O Trerotola
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ansar Z Vance
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Penn Presbyterian Medical Center, 4 Wright Saunders Building, 51 N. 39th Street, Philadelphia, PA, 19104, USA.
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Alqassieh A, Dennis PB, Mehta V, Shi J, Lin A, Taber D, Rohan V. MILLER Banding Procedure for Treatment of Dialysis Access-Related Steal Syndrome, Pulmonary Hypertension, and Heart Failure. Am Surg 2021:31348211056259. [PMID: 34794331 DOI: 10.1177/00031348211056259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) banding procedure has been used for treating patients with dialysis access-related steal syndrome (DASS) and high-flow vascular access-related pulmonary hypertension (PHT) and heart failure (HF).We performed a retrospective analysis of patients undergoing the MILLER procedure performed for DASS, HF, and PHT from our Vascular Access Database from September 2017 to October 2019. Outcomes included primary patency of banding, primary assisted patency, and secondary patency, using time-to-event analyses with Kaplan-Meier curves and life tables to estimate 6- and 12-month rates.A total of 13 patients (6 men and 7 women, mean age 60 ± 14 years) underwent the MILLER procedure, 6 patients for DASS and 7 patients for pulmonary hypertension and heart failure (PHT/HF). Technical success was achieved in all patients. The longest duration of follow-up was 28 months (median 12 months [IQR 7, 19]). One patient died at 1 month after the intervention due to stroke. One patient developed access thrombosis of the graft 3 days after the procedure. Repeat banding was required in 1 patient 8 months after the first procedure. The 6-month primary patency rate of banding following this procedure was 83% while the 12-month rate was 66%. The 6- and 12-month secondary patency rates were 87% and 75%, respectively.The MILLER procedure can be performed for DASS and PHT/HF with improvement of symptoms and good long-term patency rates. Additional interventions to maintain patency and efficacy are required on long-term follow-up.
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Affiliation(s)
- Ahmad Alqassieh
- 2345Medical University of South Carolina, Charleston, SC, USA
| | | | - Veena Mehta
- 2345Medical University of South Carolina, Charleston, SC, USA
| | - June Shi
- 2345Medical University of South Carolina, Charleston, SC, USA
| | - Angello Lin
- 2345Medical University of South Carolina, Charleston, SC, USA
| | - Dave Taber
- 2345Medical University of South Carolina, Charleston, SC, USA
| | - Vinayak Rohan
- 2345Medical University of South Carolina, Charleston, SC, USA
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Sen I, Tripathi R. Dialysis associated steal syndromes. A narrative review. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:146-154. [PMID: 34235901 DOI: 10.23736/s0021-9509.21.11830-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA -
| | - Ramesh Tripathi
- Department of Surgery, School of Medicine, University of Queensland, Queensland, Australia
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CERQUEIRA SS, FERREIRA JM, FRUTUOSO MR, EUSEBIO C, CASTRO RA, MORGADO TM. A modified banding technique: experience of a center. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.23736/s1824-4777.21.01440-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cerqueira SSG, Ferreira JM, Fructuoso MR, Eusebio C, Castro RA, Morgado TM. A modified banding technique: experience of a center. J Bras Nefrol 2020; 43:41-46. [PMID: 33179719 PMCID: PMC8061973 DOI: 10.1590/2175-8239-jbn-2020-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/09/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A well-functioning vascular access is vital to patients on regular hemodialysis. Banding the access is indicated in high-flow-associated steal syndrome. It allows for the reduction of access flow while maintaining distal limb perfusion. Nonetheless, this procedure has some limitations as it can cause hemorrhage, infection, aneurysm formation, thrombosis of access in cases of overbanding, or otherwise insufficient reduction of vascular flow. Other surgical techniques to achieve the same benefit would be useful. METHODS We performed a modified banding technique without endovascular placement of the angioplasty balloon, which is a viable alternative to other techniques. This surgery was performed in patients on chronic dialysis with steal syndrome. Pre- and post-operative access flows were measured and resolution of symptoms was recorded. Primary patency rate was defined as the intervention-free access survival from the operative time. RESULTS We verified that this technique allowed for access flow reduction in all our six patients, with total resolution of symptoms in all patients. Primary patency rate at 12 months was 100%. No major complications were noted during our follow-up. CONCLUSIONS This technique allows for correction of high-flow arteriovenous fistulas in an efficient and safe way, and can be a viable alternative to other banding procedures.
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Affiliation(s)
- Sofia S G Cerqueira
- Centro Hospitalar Trás-os-Montes e Alto Douro, Hospital de Vila Real, Serviço de Nefrologia, Vila Real, Portugal
| | - Joana M Ferreira
- Hospital da Senhora da Oliveira, Serviço de Angiologia e Cirurgia Vascular, Guimarães, Portugal
| | - Mónica R Fructuoso
- Centro Hospitalar Trás-os-Montes e Alto Douro, Hospital de Vila Real, Serviço de Nefrologia, Vila Real, Portugal
| | - Catarina Eusebio
- Centro Hospitalar Trás-os-Montes e Alto Douro, Hospital de Vila Real, Serviço de Nefrologia, Vila Real, Portugal
| | - Rui A Castro
- Centro Hospitalar Trás-os-Montes e Alto Douro, Hospital de Vila Real, Serviço de Nefrologia, Vila Real, Portugal
| | - Teresa M Morgado
- Centro Hospitalar Trás-os-Montes e Alto Douro, Hospital de Vila Real, Serviço de Nefrologia, Vila Real, Portugal
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