Abstract
BackgroundDialysis access-associated steal syndrome (DASS) is an infrequent complication after hemodialysis access creation. Clinical symptoms depend on the degree of steal. Percutaneous arteriovenous fistula creation offers a minimally invasive alternative to surgical creation, though complications have been reported. The following presents the first described case of DASS after percutaneous endovascular arteriovenous fistula creation, and discusses risk factors and management.Case PresentationOur case is that of a 27-year-old male with end stage renal disease due to congenital renal dysplasia, who underwent left percutaneous arteriovenous fistula creation for initiation of dialysis. Two months after the procedure the patient complained of coldness, pain, tingling, and numbness in the left arm during dialysis, concerning for steal syndrome. The patient subsequently underwent brachial artery angiogram, which showed minimal antegrade flow through the ulnar and interosseous arteries towards the hand, and a focal, severe stenosis in the distal ulnar artery. Angioplasty of the stenosis was performed, though steal symptoms continued.ConclusionsDASS, though rare, can be seen with percutaneous arteriovenous fistula creation. Identification of the risk factors prior to creation can help avoid this complication. Management is largely guided by clinical presentation. As long as there is adequate collateral supply to the extremity, single vessel occlusion is not a contraindication to percutaneous arteriovenous fistula creation with the use of WavelinQ technology. Careful patient selection with pre-creation angiogram may reduce the risk of symptomatic steal.
Highlights
Dialysis access-associated steal syndrome (DASS) is an infrequent complication after hemodialysis access creation
Careful patient selection with precreation angiogram may reduce the risk of symptomatic steal
One case of DASS after percutaneous arteriovenous fistula (pAVF) creation mentioned in the NEAT trial [2] was the result of closure device maldeployment within the brachial artery access leading to iatrogenically induced steal syndrome
Summary
Risk factors for DASS include female gender, age > 60years, diabetes, atherosclerosis, previous access surgeries in the affected limb, and use of proximal versus distal artery for anastomosis [1]. A smaller anastomotic diameter of 5 mm created by WavelinQ technology can result in symptomatic steal [4]. Surgical ligation of the fistula is usually considered in patients with severe symptoms [3]. Our patient had an occluded distal radial artery and a focal area of severe stenosis in the distal ulnar artery, not seen at pre-AVF creation angiography, causing an increase in the resistance between the vascular beds, promoting DASS. The angiogram showed a large diameter draining vein contributed by prior rcAVF creation, resulting in decreased vascular resistance and increased flow through the fistula. Careful patient selection with pre-creation angiogram for pAVF may reduce the risk of symptomatic steal. Author details 1Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, New Hillman Building, NHB-H623, AL 35249 Birmingham, USA.
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