Abstract
The ideal choice of vascular access in patients requiring haemodialysis is an arteriovenous fistula. However, an important often under-reported complication encountered at follow-up is symptoms of tingling or numbness in the hand. This may represent carpal tunnel syndrome, impairment of the median nerve as it traverses through the carpal tunnel at the wrist by focal compression of this nerve. Contributory factors in the presence of an arteriovenous fistula may include venous hypertension and varying steal syndrome phenomena provoking micro-ischaemia. Studies that investigated the evolution of carpal tunnel syndrome in haemodialysis patients with an arteriovenous fistula revealed that the frequency of carpal tunnel syndrome associated with an arteriovenous fistula on haemodialysis ranged from 10.4% to 42.6%. An association between duration of haemodialysis with arteriovenous fistula and carpal tunnel syndrome development was also observed. Surgical release of carpal tunnel provided complete relief of paraesthesia in all treated patients in the examined, demonstrating an alleviation of symptoms and improved function of hand and quality of life in patients with an arteriovenous fistula. However, the aetiology and risk factors for development of carpal tunnel syndrome remain unclear and further studies should attempt to elucidate the pathophysiology of this occurrence in the presence of arteriovenous fistulas.
Highlights
The ideal choice of vascular access in patients requiring haemodialysis (HD) is an arteriovenous fistula (AVF)
Of 36 patients, hand volumes were investigated in symptomatic patients to find that non-dominant hands with AVFs (18%, p < 0.001 and 21%, p < 0.01 in males and females, respectively) had an increased volume compared to age-matched controls (5.1%, p > 0.1 and 5.7%, p > 0.1 in males and females, respectively)
It is clear that the tingling hand post AVF formation presents a common diagnostic conundrum for the vascular access surgeon in the setting of other differentials such as peripheral neuropathy and vascular steal syndrome
Summary
The ideal choice of vascular access in patients requiring haemodialysis (HD) is an arteriovenous fistula (AVF). In a cohort of 19 patients with CTS on HD (17 with AVFs), early and regular screening using NCS was suggested for early detection of CTS leading to early treatment, which can include a splint or surgical decompression.[21] In the study, 85% (n = 16) reported improvement in symptoms, with only scar pain remaining in 21% (n = 4) at an average follow-up of 18.6 months. All patients treated with surgical release in this review were reported to experience partial to complete relief suggesting that carpal tunnel decompression is a worthwhile intervention for these troubling symptoms In this particular cohort of patients, presentation may be later on with more advanced symptoms and there is no scope here for non-operative measures. The authors’ recommendation is that carpal tunnel release should be performed by an experienced hand surgeon
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