Proximalization of Arterial Inflow for Treatment of Hemodialysis-Induced Arterial Steal Syndrome

Abstract

This was a retrospective analysis of proximalization of arterial inflow for treatment of hemodialysis access-related arterial steal syndrome. We performed 12 proximalization procedures during a span of 18 months. The proximalization procedure was performed by creating a bypass from the axillary artery to the arteriovenous (AV) fistula and disconnecting the AV fistula from the brachial artery inflow source. Retrospective review of data was performed to evaluate indications, outcomes, complications, and technical pitfalls. Retrospective review was conducted of patients who underwent proximalization of arterial inflow from July 2016 to March 2018. We performed this procedure on 12 patients. Indications for the procedure were intractable pain in the hand at all times in seven patients, tissue loss in three patients, and severe pain during dialysis treatment in two patients. All patients were diagnosed with arterial steal syndrome with Doppler ultrasound studies, and subsequent angiography was performed to confirm the diagnosis and to rule out inflow correctable lesions. Selection of patients for proximalization was based on relatively small size of the brachial artery in comparison to the AV fistula and low flow volumes. We used expanded polytetrafluoroethylene (ePTFE) grafts in all patients. Three patients received four to seven tapered grafts, and the remaining patients received 5-mm or 6-mm ePTFE grafts. Two patients had graft thrombosis within 30 days postoperatively. These appeared to be due to hypotension during dialysis. On further investigation, one of these had venous outflow stenosis, which was corrected by angioplasty of the venous outflow. This patient also required stenting of the anastomosis between the ePTFE graft and the fistula because of stenosis. The other patient had graft revision with a larger conduit. There was no mortality in 30 days. All patients showed improvement in perfusion of the affected hand. One patient had no significant improvement in numbness and was referred for neurologic evaluation. Two patients had partial resolution of pain. The remaining patients had resolution of pain, and all patients with tissue loss healed their ulcers. Proximalization of arterial inflow can help resolve hemodialysis access-related arterial steal syndrome in the majority of patients in whom the brachial artery is small.