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Abstract

First and foremost, thank you for your insightful comments, questions, and thoughtful consideration of our study. To address your questions in turn, the manner of presentation was dependent on the severity and timing of the onset of steal symptoms. Approximately 34% (14/41 patients) were identified and treated in the perioperative period or during initial clinical follow-up within 6 weeks, with the majority presenting to the emergency room, the dialysis access clinic, or in the immediate postoperative period with pain and motor/sensory neurologic dysfunction. Most of the remaining patients with delayed presentations and treated at >6 weeks from the time of their initial procedure were identified and re-referred during routine fistula monitoring/screening by a trained dialysis access nurse (18/41, 44%). The remaining patients (9/41, 22%) self-presented with symptoms, and the majority of these (7/9) dialyzed at centers apart from either center where the access was created. The relatively late nature between fistula creation and revision procedure for steal likely reflects an inherent selection bias, as only those with severe ischemia (Society for Vascular Surgery [SVS] grade 3) were included for analysis. Although the prospective dataset we used did not include data for the new onset of mild or moderate neurologic symptoms, anecdotally these symptoms occur frequently. Most of these patients are treated conservatively, as are all of those presenting with SVS grade 1 and most of those with SVS grade 2 steal. However, although suspected ischemic monomelic neuropathy necessitating ligation occurred in five patients in our series (0.2%), we certainly agree that this condition likely exists on a spectrum of severity and that the majority present with lesser degrees of neurologic dysfunction are underdiagnosed. To clarify, preoperative imaging is routinely performed on all cases of suspected ischemic steal syndrome at both institutions; however, this imaging is performed primarily to identify an arterial inflow lesion, with the majority of suspected steal patients investigated with computed tomography angiography. Because catheter-based angiography can demonstrate flow reversal in as many as 73% of proximal angioaccess creations (many of whom do not develop clinical steal syndrome),1Kwun K. Schanzer H. Finkler N. Haimov M. Burrows L. Hemodynamic evaluation of angioaccess procedures for hemodialysis.Vasc Surg. 1979; 13: 170-177Crossref Scopus (72) Google Scholar imaging demonstration of flow reversal is not considered mandatory at either institution when there is typical symptomatology and objective physiological evidence (digital or wrist pressures) of severe distal ischemia. The decision to perform revision using distal inflow (RUDI) or distal-revascularization-interval ligation (DRIL) at both centers is based on a combination of patient symptomatology consistent with steal syndrome, corroborating physiological tests, exclusion of a culprit inflow lesion, and the patient’s previous hemoaccess history and access requirements. Regarding “A comparison of revision using distal inflow and distal revascularization interval ligation for the management of severe access-related hand ischemia”Journal of Vascular SurgeryVol. 64Issue 5PreviewI read with great interest the article by Misskey et al1 and congratulate them on having prospective follow-up on such a large number of patients. They report that 3% of patients developed grade 3 access-related hand ischemia (ARHI). There was no difference in patency rates or resolution of symptoms between patients who underwent revision using distal inflow (RUDI) or distal-revascularization-interval ligation (DRIL) for revascularization. Full-Text PDF Open Access