Operative Techniques to Prevent Dialysis Access-associated Steal Syndrome in High-risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review.

Fareed Ahmed Shaikh,Amna Riaz,Nadeem A Siddiqui,Noman Shahzad,Ziad Sophie

doi:10.7759/cureus.6086

Abstract

Up to 10% of patients suffer from various degrees of dialysis access-associated steal syndrome (DASS) after surgery for hemodialysis access. This systematic review was conducted to find out optimal intra-operative techniques to prevent DASS in high-risk patients.This systematic review is registered with PROSPERO (2017:CRD42017060804). It was conducted at Department of Surgery, Aga Khan University Hospital, Karachi. All types of studies conducted on intra-operative techniques to prevent DASS in high-risk population (Age > 60 years, female gender, diabetes mellitus, peripheral arterial disease and previous DASS) undergoing access creation from January 1990 till April 2019 were included in the systematic review. Thorough search was conducted on Pubmed, Google Scholar and Cochrane databases to identify relevant articles. Included studies reviewed for success of various techniques to prevent dialysis access steal syndrome are summarized.Out of 125 studies in the initial search, six met the inclusion criteria. Five were retrospective case series while one was a case report. The largest study sample size was 32. All but one study had arterio-venous access creation on an arm. “Proximalization of arterial inflow” was described in three and “prophylactic distal revascularization and interval ligation (DRIL) procedure” in two studies to prevent DASS. Only one patient out of these studies developed DASS at an overall follow-up of 7-42 months.Proximalization of inflow has been reported as the most common procedure performed to prevent DASS followed by extension technique and DRIL procedure. All three procedures have satisfactory outcome with no clear superiority of one over the other.

Highlights

BackgroundEnd stage renal disease (ESRD) affects more than 1500 people per million population per year
All types of studies conducted on intra-operative techniques to prevent Dialysis access-associated steal syndrome (DASS) in high-risk population (Age > 60 years, female gender, diabetes mellitus, peripheral arterial disease and previous DASS) undergoing access creation from January 1990 till April 2019 were included in the systematic review
Included studies reviewed for success of various techniques to prevent dialysis access steal syndrome are summarized

Summary

Introduction

End stage renal disease (ESRD) affects more than 1500 people per million population per year. These include age more than 60 years, diabetes mellitus, female gender, peripheral arterial disease, and history of previous DASS [3,4,5,6] In these high-risk patients simultaneous prophylactic procedure to prevent DASS along with index AV access surgery for haemodialysis has been reported to reduce the morbidity [7,8,9,10]. The principle of prophylactic DRIL (Distal Revascularization and Interval Ligation) remains same when it is applied for treatment of DASS, i.e., both the fistula and distal limb are perfused simultaneously and reversal of flow is prevented by interval ligation, as depicted in schematic diagram (Figure 3) [14] It was first described by Schanzer et al in 1988 with a technical success of 90% and bypass patency of 80% at four years [15]. Comparative efficacy of these techniques is not known [7,8,9]

Objective

Results

Study design

Disclosures