Dialysis Access-associated Steal Syndrome Research Articles

Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques.

This systematic review and meta-analysis examine preventive operative techniques in high-risk patients undergoing surgery for hemodialysis access to mitigate the risk of Dialysis Access-Associated Steal Syndrome (DASS). Chronic kidney disease often leads to end-stage renal disease (ESRD), necessitating dialysis. Successful vascular access is crucial for efficient dialysis, but complications, such as DASS, pose significant challenges. DASS redirects arterial blood flow, affecting populations undergoing arteriovenous access surgery. This study aims to assess preventive strategies, including distal revascularization with interval ligation (DRIL) and extension techniques. A systematic search of PubMed, Cochrane Library, EMBASE, and Web of Science until 2022 identified 11 relevant studies. The inclusion criteria comprised non-pediatric hemodialysis patients reporting outcomes related to patency and complications. The data were analyzed using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Meta-analysis indicated a significant association between DASS and arteriovenous fistula (AVF) or arteriovenous graft (AVG) procedures. Radiocephalic AVF (RC-AVF) and distal endovascular AVF procedures were favored. Various interventions addressed venous narrowing, including simple plication and loop interposition. The Modified by Inserted Latex Link for Endovascular Repair (MILLER) technique, DRIL, Extension Technique, and Proximalization of Arterial Inflow (PAI) were assessed for arterial bypass graft and blood supply preservation. This study underscores the importance of individualized strategies in preventing DASS during hemodialysis access surgery. Prophylactic measures, such as the extension technique, show promise, while DRIL remains effective in treatment. Ongoing research is imperative for optimizing outcomes in this complex patient population.

Safety of bilateral arm pressure measurements in the diagnostic workup of dialysis-associated steal syndrome.

Although bilateral brachial pressure measurement is routinely included in the diagnostic work-up of upper extremity ischemia, it is generally avoided in the presence of hemodialysis access due to fears of inducing access thrombosis. This study evaluated the safety of bilateral brachial pressure measurement in patients with clinical suspicion of dialysis-associated steal syndrome (DASS). Patients undergoing non-invasive testing for steal syndrome between September 2015 and December 2021 were included in this study. The diagnostic workup was performed by certified vascular sonographers in an outpatient vascular lab and consisted of bilateral brachial pressures, photoplethysmography, and duplex ultrasonography of the access. Interarm differential (IAD) was defined as systolic blood pressure (SBP) in the contralateral arm minus SBP in the access arm. The primary endpoint was immediate access thrombosis. The study sample consisted of 331 subjects with a mean age of 61 ± 13 and a median access age of 9 months (3-31 months) with radiocephalic fistulas present in 29%. Many patients (68%) presented with paresthesia and 4% presented with tissue loss. The mean brachial systolic pressure was 152 ± 37 mmHg on the ipsilateral arm versus 143 ± 34 mmHg on the contralateral (p-value <0.001), with an inter-arm differential (IAD) of -8.4 ± 19 mmHg. A total of 16 subjects (5%) presented a differential ⩾20 mmHg. A positive thrill was noted in all the accesses immediately following blood pressure measurement and no occurrence of access thrombosis was noted at 30 days. Proximal arterial revascularization interventions were performed in 11 cases (3%). Subjects who presented an IAD ⩾20 mmHg had lower ipsilateral digital-brachial index (0.39 ± 0.18 vs 0.68 ± 0.26; p = 0.037), a higher tendency of being referred for angiograms (37.5% vs 10.5%, p = 0.006), and more proximal arterial revascularization procedures (25.0% vs 2.2%, p = 0.001). Bilateral arm pressure measurement in the context of dialysis access-associated steal syndrome (DASS) appears safe and useful for identifying subjects whose symptoms are due to proximal arterial inflow disease. We therefore recommend this test be considered in the diagnostic algorithms of DASS.

Efficacy of Revision Using Distal Inflow in Patients with Symptomatic Dialysis Access-Associated Steal Syndrome.

Objectives: In this study, we aim to assess the efficacy of revision using distal inflow (RUDI) in patients with symptomatic dialysis access-associated steal syndrome (DASS). Materials and Methods: All consecutive patients who were diagnosed with grade 3 or 4 DASS and have undergone RUDI in 4 years were included in this study. Results: In total, 35 patients were included in this study; participants had a mean age of 47.5±7.52 years and 54% (n=19) were males. As per our findings, significant improvement was noted in terms of paresthesia (81.2%, p-value: 0.012), coolness (79.4%, p-value: 0.006), pain (78.1%, p-value: 0.006), discoloration (76.4%, p-value: 0.044), paresis (71.4%, p-value: 0.016), and ulcer healing (50%, p-value: 0.044). Gangrene did not further progress in all patients (n=35). Reduction in fistula flow rate after RUDI was 57.5% (682±121 ml/min, p-value: 0.001). Digital systolic pressure was noted to improve by 71.4% (60±9.2 mmHg, p-value: 0.002) after RUDI. Peak systolic velocity increased in both ulnar (66.1±8.2 cm/s, p-value: 0.04) and radial (64.2±7.6 cm/s, p-value: 0.024) arteries of the wrist. Cumulative patency of RUDI graft was 100%, 91.4%, and 85.7% at 3, 6, and 12 months, respectively. Conclusion: RUDI has resulted in significant improvements in terms of DASS symptoms. Using a native vein as conduit, RUDI should be considered a procedure of choice for patients with high-flow DASS.

Modified Miller banding technique for ischemia in native fistulae

Treating upper limb ischemia or dialysis access-associated steal syndrome (DASS) is controversial. Many treatments have been described for this pathology; one of the techniques of preference in our institution is banding with the technique described by Miller et al. of minimally invasive endoluminal-assisted limited ligation revision (MILLER), in which we have modified to avoid the intercurrences it causes. Four cases of stage II steal are presented in which the Miller technique is performed in which, instead of banding with a 2-0 Prolene suture, it is surrounded with a 1 cm wide PTFE segment. An angioplasty balloon is used to calibrate the desired diameter of the banding, and a Doppler ultrasound is performed to evaluate the flow before and after the procedure, as in the Miller technique. The procedure allowed ischemia to be resolved, and the fistulas were found to be permeable without evidence of the complications usually described.

Novel Endovascular Techniques for Dialysis Access-Associated Steal Syndrome (DASS)

End-stage renal disease patients with arteriovenous fistula (AVF) encounter many vascular risks related to reduced or increased arteriovenous fistula flow. Dialysis access-associated steal syndrome is one of the devastating complications that may lead to limb loss. Multiple vascular techniques (surgical and endovascular) can be used to correct this complication. In this article, we present two endovascular approaches. One approach uses a stent graft covering two thirds of anastomosis for arteriovenous fistulas to generate artificial stenosis and divert more flow to the hand. The other approach applies Supera® stent jailing to the arteriovenous fistula to divert more flow to the hand. Over 12 months of follow up, there was no clinical manifestation of dialysis access-associated steal syndrome and the AV fistula continued to function.

Dialysis Access-Associated Steal Syndrome and Management.

Dialysis-associated steal syndrome (DASS) occurs in 1-8% of hemodialysis patients with arteriovenous (AV) access. Major risk factors include use of the brachial artery for access creation, female sex, diabetes, and age > 60years. DASS carries severe patient morbidity including tissue or limb loss if not recognized and managed promptly, as well as increased mortality. Diagnosis of DASS requires a directed history and physical exam supported by non-invasive testing. Prior to definitive therapy, detailed arteriography, fistulography, and flow measurements are performed to delineate underlying etiologies and guide management. To optimize success, DASS treatment should be individualized according to access location, underlying vascular disease, flow dynamics, and provider expertise. Possible causes of DASS include extremity inflow or outflow arterial occlusive disease, high AV access flow rate, and reversal of distal extremity arterial blood flow; DASS may also exist without any of the prior features. Depending on the DASS etiology, various endovascular and/or surgical interventions should be considered. Regardless, in the majority of patients presenting with DASS, access preservation can be achieved.

Distal Radial Artery Ligation for Dialysis Access Steal Syndrome

Renal replacement therapy is the definitive treatment for end stage renal disease apart from transplant. Steal syndrome, which can lead to distal limb ischemia, is a rare but serious complication in patients who undergo hemodialysis with an arteriovenous fistula. We present a case of a 48-year-old female with limited options for dialysis access who presented with symptoms of steal syndrome. Given the need to keep her current fistula, we opted to treat her with distal radial artery ligation. This case report summarizes the various surgical techniques available for treating dialysis access-associated steal syndrome and why distal radial artery ligation should be considered a viable management strategy, especially in the context of our patient.

Dialysis access-associated steal syndrome with percutaneous endovascular arteriovenous fistula creation

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.

Distal Radial Artery Ligation for Dialysis Access Steal Syndrome

Renal replacement therapy is the definitive treatment for end stage renal disease apart from transplant. Steal syndrome, which can lead to distal limb ischemia, is a rare but serious complication in patients who undergo hemodialysis with an arteriovenous fistula. We present a case of a 48-year-old female with limited options for dialysis access who presented with symptoms of steal syndrome. Given the need to keep her current fistula, we opted to treat her with distal radial artery ligation. This case report summarizes the various surgical techniques available for treating dialysis access-associated steal syndrome and why distal radial artery ligation should be considered a viable management strategy, especially in the context of our patient.

Combination of Basilic Vein Transposition and Proximalization of the Arterial Inflow for Management of a Patient with Limited Puncture Sites and the Dialysis Access-associated Steal Syndrome: Case Report

Combination of Basilic Vein Transposition and Proximalization of the Arterial Inflow for Management of a Patient with Limited Puncture Sites and the Dialysis Access-associated Steal Syndrome: Case Report

A case of refractory dialysis access-associated steal syndrome successfully treated by additional stellate ganglion block

A case of refractory dialysis access-associated steal syndrome successfully treated by additional stellate ganglion block

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

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.

A Case of Brachiocephalic Fistula Steal and the Emergency Physician's Approach to Hemodialysis Arteriovenous Fistula Complications

BackgroundChronic kidney disease is common in the United States, with many patients maintained on hemodialysis (HD). The process of HD requires vascular access through an arteriovenous (AV) fistula, AV graft, or central venous catheter. Today, as a result of the National Kidney Foundation's “Fistula First” initiative, nearly 55% of HD patients utilize an AV fistula. As there is significant morbidity and mortality associated with fistula placement and recurrent fistula cannulation, emergency physicians must be equipped to recognize and treat fistula complications. ObjectiveTo detail a case study of vascular insufficiency (vascular steal) presenting to an emergency department (ED) and provide an evidence-based approach to the emergency assessment and management of HD AV fistula complications. DiscussionA 66-year-old man presented to the ED with left upper extremity pain, paresthesias, and loss of grip strength of 1-week duration 15 days after placement of left upper extremity brachiocephalic fistula. He was diagnosed with dialysis access-associated steal syndrome and taken to the operating room for revision. Patients with HD fistulas may experience several complications, including vascular insufficiency, hemorrhage, infection, stenosis, thrombosis, aneurysms, or pseudoaneurysms. Emergency physicians must be able to identify these complications and deliver timely treatment. ConclusionsA comprehensive understanding of the appropriate management of AV fistula complications is paramount for the emergency physician. Early recognition and treatment of vascular insufficiency resulting from fistula creation, fistula hemorrhage, fistula infection, stenosis, thrombosis, and aneurysms or pseudoaneurysms is vital to reducing the morbidity and mortality associated with HD.

Dilator-assisted banding and beyond: proposing an algorithm for managing dialysis access-associated steal syndrome.

Dialysis access-associated steal syndrome (DASS) is a major complication of arteriovenous hemodialysis accesses. Although its underlying pathology is diverse, it is most often associated with excessive access flow. Dilator-assisted banding (DAB) is a simple flow-reduction technique that we described previously. This report is to illustrate the expansion of DAB and analyze the outcome of DAB in managing DASS. From February 2011 to April 2015, 30 patients underwent DAB for DASS. Their relevant clinical data were retrospectively reviewed or prospectively collected, and further analyzed statistically. Of the 30 patients, 23 had an arteriogram and 3 required angioplasty ± stent placement for inflow artery stenosis. Besides intraluminal DAB (12/30), this report also included extraluminal DAB (14/30) and open fistula reduction plus DAB (4/30). After DAB, the severity scores of DASS were reduced from 2.8 ± 0.4 to 0.2 ± 0.4 for the fistula group (n = 24, p&lt;0.001) and from 3.0 ± 0.0 to 1.2 ± 1.2 for the graft group (n = 6, p = 0.041). DAB was effective in all but two graft patients who subsequently underwent proximalization of arterial inflow (PAI) that resulted in resolution of DASS. During follow-up of 18.7 ± 14.5 months (range 1-50), all accesses remained functional. At 24-months post-DAB, the primary patency, primary-assisted patency and secondary patency rates of the fistula group were 72%, 91% and 100%, respectively. DAB is a simple, effective and versatile approach for managing DASS. PAI may be employed for rescue or as primary choice when banding is ineffective. Based on our data and the literature, an algorithm is proposed for managing DASS.

Management and outcomes of dialysis access-associated steal syndrome

Dialysis access-associated steal syndrome (DASS) complicates arteriovenous access surgery. We describe a 10-year experience with the surgical management of DASS. DASS operations were retrospectively reviewed from July 2003 to July 2013 from a single academic institution. Demographics, symptoms, surgical details, and outcomes were collected. A total of 201 patients had 218 episodes of DASS. Mean age was 65 years, and 62% were women. DASS was caused by 175 arteriovenous fistulas (80%), 41 upper extremity prosthetic grafts (19%), and two thigh grafts (1%); 87% were brachial artery based. A portion (22%) were referred for DASS from outside practices. All patients had grade 2 (48%) or grade 3 (52%) DASS; 92% (185) were available for follow-up, with a median time to first follow-up of 23 days. Surgical procedures included ligation (73), distal revascularization with interval ligation (DRIL) (59), revision using distal inflow (RUDI) (21), banding (38), proximalization of arterial inflow (12), and distal radial artery ligation (13). There were no differences in preoperative comorbidities between treatment groups. The 30-day complications included continued steal, thrombosis, bleeding, infection, and mortality. Ligation and DRIL were performed most often for grade 3 steal. Ligation and banding were performed most acutely (median time to intervention after access creation of 39 and 24 days vs DRIL and RUDI at 97 and 100 days). Fistula preservation was 0% for ligation, 100% for DRIL, 95% for RUDI, and 89% for banding (P < .01). Improvement of symptoms ranged from 75% (banding) to 98% (DRIL) (P = .005). Women were less likely to have DRIL but more likely to have ligation (P = .001). Complications were highest in the banding (49%) and RUDI (37%) groups. Average mortality was 3.5%, with no significant differences among groups. During the study period, 3287 access procedures were performed, and access volume steadily increased (2003-2008, 1312 access creations; 2008-2013, 1975). Percentage of fistulas (79% vs 86%), incidence of steal (4% vs 6%), and percentage of DRILs (25% vs 28%) were consistent across the two study periods. DRIL and ligation were performed in patients with the most severe symptoms. Compared with ligation, DRIL has equal symptom resolution, no increase in complications, and fistula preservation. Compared with banding, DRIL resulted in superior fistula preservation and fewer complications. DRIL should be considered the preferred procedure for management of DASS in patients with a functioning autologous fistula who can tolerate a major operation.

SS21 Dialysis Access-Associated Steal Syndrome Management and Outcomes: A 10-Year Experience

mortality (adjusted hazard ratio [HR], 1.03; P < .001). Compared with patients with IHC (N 1⁄4 419,009), overall risk-adjusted mortality was lowest in patients with AVF (N 1⁄4 71,328; HR, 0.65; P < .001), followed by AVG (N 1⁄4 17,544; HR, 0.83; P < .001). AVF was superior to IHC and AVG for all age groups (P < .001; Fig 1). However, there was a significant change in the relative efficacy of AVG at age 45 based on spline modeling: there were no differences comparing AVG to IHC for patients aged 18 to 44 years (adjusted HR, 0.90; P 1⁄4 .12), but AVG was superior to IHC for patients aged $45 years (adjusted HR, 0.82; P < .001). Conclusions: Contrary to previous reports, our data suggest that AVF is superior to AVG and IHC regardless of patient age, including in octogenarians. In contrast, the mortality benefit of AVG over IHC may not apply to younger age groups. All patients aged <45 years should receive AVF for dialysis access whenever possible.

Distalization of the Anastomosis: An Effective Treatment for Dialysis Access–Associated Steal Syndrome

Steal syndrome after arteriovenous fistula formation for dialysis access can cause ischemic pain and tissue loss. This is an indication for surgical revision, usually either banding (or ligation) or the distal revascularisation and interval ligation procedure. However, banding is inexact, and distal revascularisation and interval ligation can further compromise the arterial supply to the arm. We report three cases in which an alternative approach of moving the arteriovenous anastomosis distally was used, thereby protecting arterial inflow to the hand. In all three cases, the steal resolved and the fistula remained patent.

Management of Dialysis Access-Associated “Steal” Syndrome with DRIL Procedure: Challenges and Clinical Outcomes

The distal revascularization interval-ligation (DRIL) procedure has demonstrated efficacy in the management of dialysis access-associated steal syndrome (DASS); however, this has not been widely used because of concerns about complexity, risk of ligating a native artery, and lack of long-term outcomes. Retrospective review of all patients with DASS who underwent DRIL procedure from March 2005 to August 2011. Indications, clinical considerations, bypass grafts, and patency rates were determined; complications, reinterventions, and factors influencing their outcomes were studied. 33 patients, (70% women, mean age of 56 ± 13) with DASS underwent a DRIL. Indications were ischemic pain alone in 12 (36%) patients, loss of neurologic function in 7 (21%), both ischemic pain and loss of neurologic function in 4 (12%) tissue loss in 7 (21%), pain during hemodialysis in one (3%), and "prophylactic" DRIL during a femoral vein transposition (FVt) fistula in two (6%). Technical success was 100%; Ischemic symptoms fully resolved by DRIL in 24 of the 31 symptomatic patients (77%) and during the follow up period DASS did not develop in the subjects we judged at high risk and underwent DRIL during FVt. One serious complication occurred because of early bypass thrombosis causing worsening hand gangrene requiring transmetacarpal amputation. The primary, assisted-primary, and secondary patency rates of the arterial bypass at 12 months were 65%, 75%, and 95% respectively. AV access primary, assisted-primary, and secondary patency were 29%, 85%, and 94% at 12 months. DRIL procedure is effective at relieving symptoms in carefully selected patients, but does have potential complications such as bypass failure and worsened ischemia. DASS remains a complex clinical entity in that it is not fully understood, and deserves further study.

Treatment of dialysis access-associated steal syndrome with pressure monitorization-assisted PTFE banding

Background: We evaluated the mid-term effects on the fistula patency and clinical results of our technique of banding combined with pressure measurement from the distal bed. Methods: The mid-term results of 20 patients who were diagnosed with symptomatic steal syndrome by clinical and Doppler USG evaluation and treated with arterially pressure monitorized polytetrafluoroethylene (PTFE) banding method between January 2002 - December 2009 were studied. All the patients had aneurysmatic brachiocephalic arteriovenous fistula (AVF). Peroperatively, blood pressure was monitorized from the proximal of the fistula, brachial artery and radial artery and the radial/ brachial index values were recorded. Fistulas were constricted until the lower treshold of the radial-brachial index became 0.6. For the banding procedure PTFE grafts long enough to completely cover the aneurysmatic segment were used. Postoperatively, patients were asked to return for follow-ups within the 1st month and at three-month intervals thereafter. The fistula patency and the symptoms were evaluated and recorded in the follow-ups. Results: Symptoms were not alleviated in three patients at the 1st month follow-up. These patients underwent rebanding. In the remaining patients no early or late complications developed. All patients could receive hemodialysis in the early period and the symptoms were resolved. Other than the two patients who underwent rebanding, no cases of thrombosis were detected at the end of the first year. Conclusion: The main surgical procedures for surgical treatment of post-AVF steal syndrome are distal revascularization-interval ligation, banding, T-banding, graft interpositioning and AVF ligation. There are no large surgery studies involving patients treated with these methods. While banding procedure is technically easy, insufficient banding causes perpetuation of steal syndrome and more than necessary constriction causes thrombosis. In this study one year patency and thrombosis rates were 90% and 10%, respectively and the rate of relief of symptoms was 95%. We think that controlled banding with brachial and radial artery pressure monitoring reduces risk of fistula thrombosis and repeat procedures for insufficient constructions.

Treatment of Dialysis Access-associated Steal Syndrome with the “Revision Using Distal Inflow” Technique

Dialysis access-associated steal syndrome (DASS) is a common, serious complication of antecubital fossa (ACF) arteriovenous fistulas (AVFs). We describe our experience of the "revision using distal inflow" (RUDI) technique for the treatment of DASS and review the literature. Patients underwent fistula ligation at the anastomosis with re-establishment of inflow via the proximal radial or ulnar arteries using a venous interposition graft or venous collateral. A retrospective analysis of outcomes of all patients undergoing this procedure at our center was carried out. Seven patients with autogenous ACF AVFs underwent the RUDI procedure, four under local anesthesia. Interposition vein grafts were used in five patients, and inflow was achieved through the proximal radial artery in four cases. The median post-operative rise in digital systolic blood pressure was 65.5 mmHg. Follow-up at 7-36 months found that three fistulas had failed (one at 8 months, two within days), two patients had died with patent fistulas, one patient was transplanted with a functional AVF, and the remaining patient continues to dialyze through the fistula. No patients developed DASS post-operatively and no further interventions were required to maintain patency. Although RUDI was successful at treating DASS, a high rate of AVF failure was seen. With technical modifications and further experience, RUDI may become a valuable tool in the surgical armamentarium.