Revision Using Distal Inflow: A Safe and Effective Treatment for Ischemic Steal Syndrome After Access Creation

Abstract

Ischemic steal syndrome (ISS) is a dreaded complication after hemodialysis access creation. Its management is complex and varied, with most requiring surgical revision for correction of symptoms. Revision using distal inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience with RUDI for the treatment of ISS and pathologic high flow (HF). We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April 2010 to March 2014. Data collection included demographics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. We performed 32 RUDI procedures in 31 patients (18 women, 13 men). Indications for surgery were pathologic HF in 15 and ISS in 21. Sixteen percent had prior plication for ISS or HF. Seventy-one percent of patients had a history of diabetes, and 52% had a history of atherosclerotic disease. Time to intervention from creation was 40 months (range, 6-88 months). Accesses included one upper arm graft and 30 brachial artery-based fistulas. Outflow included 26 cephalic veins and four basilic veins. Distalization targets were 20 radial arteries, nine ulnar arteries, and three distal brachial arteries. Mean flow reduction was 994 mL/min. Primary assisted patency at 1 year was 73%, and secondary patency was 88%. The RUDI in one patient was revised from a distal brachial to radial inflow. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 81% and partial in 19%. RUDI is an effective and lasting treatment of ISS and HF and comparable to reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and plication. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.