Dialysis Access Steal Syndrome Research Articles

Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution’s 20-Year Experience

PurposeTo determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS). Materials and MethodsA retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions. ResultsTechnical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups. ConclusionsIn this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.

Overview of hemodialysis access and assessment.

To provide family physicians with an evidence-based overview on the various methods of vascular access for hemodialysis (HD) and to provide a framework for the clinical assessment of HD access. A MEDLINE literature search was conducted using the MeSH terms arteriovenous fistula, arteriovenous graft, central venous catheter, and hemodialysis (or haemodialysis), including all relevant English-language articles published between January 1995 and September 2021. The main types of permanent vascular access for HD are arteriovenous fistulas, arteriovenous grafts, and central venous catheters. A pragmatic, patient-centred approach is required when choosing the type of access for an individual. Common complications of vascular access creation include thrombosis, central venous stenosis, dialysis access steal syndrome, and arteriovenous fistula aneurysms. Family physicians play an important role in the clinical assessment and monitoring of HD vascular access. A thorough clinical assessment can detect a failing arteriovenous fistula and any associated complications, which can allow for prompt investigation and intervention to restore functionality, maintain access longevity, and improve patient quality of life.

Abstract No. 205 Percutaneous angioplasty of distal brachial artery stenosis in dialysis access steal syndrome can result in clinically successful outcomes

There is a common belief, grounded in previous hemodynamic research,1 that PTA of a brachial artery (BA) stenosis peripheral to hemodialysis access anastomosis would worsen dialysis access steal syndrome (DASS) by permitting greater retrograde flow into the access. To test this theory, this study compared outcomes of DASS patients who did versus did not receive PTA for distal BA stenosis.

Abstract No. 212 Percutaneous management of dialysis access steal syndrome can reduce need for surgery: outcomes from a single institution 20-year experience

Abstract No. 212 Percutaneous management of dialysis access steal syndrome can reduce need for surgery: outcomes from a single institution 20-year experience

Proximalization of Arterial Inflow Versus Banding for the Management of Hemodialysis Access Steal Syndrome

Clinical findings in dialysis access steal syndrome (DASS) include asymptomatic flow reversal, hand ischemia, and tissue loss. Treatment options include proximalization of the arterial inflow (PAI) and banding, both of which have been established as acceptable alternatives to distal revascularization with interval ligation. We directly compared outcomes among patients undergoing PAI and banding for symptomatic DASS.

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.

Treatment options for dialysis access steal syndrome.

Vascular access-induced limb ischemia is a known complication of arteriovenous fistulas and grafts. Many techniques have been adopted to prevent steal in high-risk patients and to treat steal in cases of moderate ischemia not controlled with conservative management. A major factor guiding treatment is access flow volume. Management is different when ischemia is combined with the excessive flow in contrast to the combination with normal flow. We describe the most popular techniques encountered in the English literature as a part of a stepwise approach to treating dialysis access steal syndrome. In absence of ischemia, when cardiac issues emerge due to extreme access flow volumes, some of these techniques are also used to decrease flow and protect the heart. Patient’s history, focused clinical examination, color duplex ultrasound examination, pulse oximetry and an angiogram are essential tools to approach this entity.

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.

Pathophysiology of High Flow Access and Surgical Flow Reduction Procedures

High flow access (HFA) is a condition in which hemodynamics is affected by a flow rate that is larger than the blood flow required for hemodialysis. HFA sometimes causes high output heart failure, venous hypertension, and dialysis access steal syndrome. Flow reduction is effective for improving symptoms, and various surgical procedures have been reported. HFA is recognized as a well-developed type of access due to its good access sound, thrill, and vessel diameter; also, HFA probably has good patency if not intervened with by flow reduction. Therefore, the blood flow reduction procedures used to treat HFA need to minimize disadvantages such as access thrombosis, insufficient blood flow, aneurysm formation, and infection due to therapeutic intervention while, at the same time, achieving symptom improvement and long-term patency. The surgical procedure used to correct HFA must be highly reproducible and simple. This article reviews the pathophysiology and surgical flow reduction procedures for HFA.

Dialysis-associated steal syndromes.

The aim of this article is to review contemporary concepts in the genesis of dialysis access steal syndrome (DASS) and its current management. An electronic search of literature from 1960 to 2020 in PubMed and the Cochrane library was conducted and practice guidelines were examined. Search terms included dialysis, steal, ischemia, access and ESRD. Clinical presentation, pathophysiology, risk factors, diagnostic techniques and management outcomes of extremity ischemia following dialysis access creation were reviewed. Symptomatic steal occurs in 4-10% of patietns after creation of hemodialysis access creation. Risk factos include brachial based fistula, diabetes, female sex, coronary heart disease, cerebrovascular disease, tobacco use, age more than 60 and hypertension. Diagnosis is mainly clinical and can be aided by non invasive testing. Correction o finflow stenosis, Distal revasulatisation with interval ligation, revision using distal inflow or other techniques are useful for fistula preservation. Dialysis-associated steal syndromes have a complex haemodynamic causation. Clinical presentation is diagnostic; however when the diagnosis is uncertain adjunctive non-invasive perfusion tests, duplex and other imaging amy be required. Management is guided by anatomic, patient and disease-related considerations.

Distal Revascularization and Interval Ligation for the Management of Dialysis Access Steal Syndrome

Treatment options for dialysis access steal syndrome (DASS) include distal revascularization with interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. This study examines the efficacy of DRIL in treating DASS and reports short-term bypass patency, access patency, and wound infection rates. A retrospective analysis was performed on adults diagnosed with DASS following hemo-dialysis access creation who underwent DRIL procedures between January 1, 2009 and May 11, 2017. Patients <18 years and those with lower extremity accesses or HeRO grafts that developed DASS were excluded. Data was obtained using electronic medical records and analyzed using SPSS software. Residual steal was defined as reintervention for DASS within 60 days of DRIL. Recurrent steal was defined as reintervention beyond 60 days. Eighty-nine DRIL procedures were performed for correction of DASS. Population included 59.6% female (n = 53), 47.2% current/former smokers (n = 42), 76.4% diabetic (n = 68), and 79.8% AVF (n = 71). Symptom resolution was complete for 69.7% (n = 62), and partial for 25.8% (n = 23), with no improvement in 4.5% (n = 4). Following DRIL, mean DBI improved from 0.43 to 0.67 (P= 0.002). Mean steal classification improved from 3.04 to 0.64 (P< 0.001). Five patients required a subsequent procedure for DASS symptoms - 3 for residual steal and 2 for recurrent steal. Bypass patency at 6 months post DRIL was 93.3% (n = 83) primary, 97.8% (n = 87) primary-assisted, and 100% (n = 89) secondary patency. Access patency at 6 months post DRIL was 78.7% (n = 70) primary, 91% (n = 81) primary-assisted, and 94.4% (n = 84) secondary. Twenty-one patients (23.5%) had 24 cases of surgical site infections, with 70.8% (n = 17) occurring at the saphenectomy site. Wound infections re-solved within 60 days postoperatively in 23 out of 24 patients. DRIL is highly effective in relieving symptoms of DASS and has excellent rates of short-term access and bypass patency. However, consideration must be given to the high wound infection rate and the potential need for subsequent procedures.

Feasibility of a 3 mm arteriotomy for brachiocephalic fistula formation.

The arteriovenous fistula is the modality of choice for long-term haemodialysis access. We describe the feasibility of routinely fashioning a brachiocephalic fistula utilising a 3 mm long arteriotomy in an attempt to reduce the incidence of symptomatic steal syndrome yet while maintaining satisfactory clinical outcomes. All patients who underwent brachiocephalic fistula formation using a routine 3 mm long arteriotomy within Hammersmith Hospital between January 2017 and March 2018 were included. Primary outcomes included primary failure, failure of maturation, secondary patency and steal syndrome. Sixty-eight brachiocephalic arteriovenous fistula were fashioned utilising a 3 mm long arteriotomy during the study period. Mean age was 60.5 years with 59% having a history of diabetes mellitus. Mean followup was 368 days. Primary failure occurred in 10 (14.7%) patients. Cannulation was achieved in 67.3% of remaining fistula within 3-months, rising to 87.3% by 6-months. Primary patency at 6 and 12 months was 76% and 69%, respectively. Secondary patency at 6 and 12 months was 94% and 91%, respectively. Dialysis access steal syndrome was clinically apparent in three (4.4%) patients with all cases being managed conservatively. A 3 mm long arteriotomy may be routinely utilised for brachiocephalic fistula creation in an attempt to limit the incidence of steal syndrome yet while maintaining clinical patency outcomes.

Dialysis Access Steal Syndrome

The current literature indicates that patients who are dependent on dialysis are more frequent users of ED services, with patients on dialysis presenting 8.5 times more frequently than the general population.1 Patients on dialysis are at risk for a variety of medical emergencies related to the complications of chronic renal disease and dialysis treatment. It is important for emergency nurses to recognize abnormalities upon assessment to promote optimal outcomes for these patients. One serious complication, although uncommon (6% incidence), is dialysis access steal syndrome.

Comparison of the digital brachial pressure index and skin perfusion pressure as tools for diagnosing dialysis access steal syndrome

Comparison of the digital brachial pressure index and skin perfusion pressure as tools for diagnosing dialysis access steal syndrome

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.

The systematic analysis of distal revascularization with interval ligation for dialysis access steal syndrome

This report is the first systematic review of the distal revascularization with interval ligation (DRIL) procedure using standardized quality assessment methodology (Oxford critical appraisal skills and recommendation for practice using National Institute for Health and Care Excellence checklist). In this study, 22 publications with 459 patients with dialysis access steal syndrome (DASS) treated with DRIL were analyzed.1 The conclusion was that the DRIL procedure is an effective treatment for various grades of DASS.

VESS12. Is It Worth It? Distal Revascularization and Interval Ligation for Management of Dialysis Access Steal Syndrome

VESS12. Is It Worth It? Distal Revascularization and Interval Ligation for Management of Dialysis Access Steal Syndrome

Evaluation of the proximal radio cephalic arteriovenous fistula for hemodialysis

Objective To evaluate the proximal radiocephalic arteriovenous fistula (pRCF) as a hemodialysis access. Background The gold standard arteriovenous fistula is the distal radiocephalic fistula at wrist. If distal vessels are not suitable, a brachiocephalic fistula is a good vascular access, but many cases were reported to have dialysis access steal syndrome, so doing pRCF is a good alternative option. Patients and methods A prospective study was conducted on 30 patients who were in need for hemodialysis access between May 2016 to November 2016 and follow-up of patients was carried out until May 2017 at Menoufia University Hospital. The data for primary success rate, primary patency, secondary patency rates, and complications were collected and analyzed. Results Thirty patients underwent pRCF. Primary fistula failure was seen in 0%, whereas six (20%) fistulas failed later, four of them owing to thrombosis, one owing to anastomotic aneurysm, and one owing to extensive edema. Two (6.7%) patients were lost (censored) to follow-up. No patients developed steal syndrome, and the incidence of it was 0%. One (3.3%) fistula showed weak flow. Primary patency rate was 63.3%, whereas secondary patency rate was 73.3%. Conclusion For patients with prior forearm arterio-venous (AV) fistula dysfunction, or inadequate wrist vessels, we believe that a proximal radiocephalic approach should precede creation of brachiocephalic fistula to avoid the risk of dialysis-associated steal syndrome.

Utility of ultrasonography in venous hypertension and dialysis access steal syndrome

Utility of ultrasonography in venous hypertension and dialysis access steal syndrome

Revision Using Distal Inflow for the Treatment of Dialysis Access Steal Syndrome: A Systematic Review.

The aim of this systematic review is to establish the efficacy of revision using distal inflow (RUDI) on the primary endpoints of complete dialysis access steal syndrome (DASS) resolution and arteriovenous fistula (AVF) longevity. An electronic search of literature from 1966 to 2017 in CINAHL, Medline, Embase and the Cochrane library according to PRISMA standards was conducted. Quality evaluations and recommendations for practice were examined. Data on power, age, gender, comorbidities, arterial inflow, conduit material, fistulae type, follow-up, failure incidence, ischaemia grade, modality of diagnosis, morbidity and mortality were subjected to pooled analysis of prevalence at a 95% confidence interval (CI). Eleven studies involving 130 individuals with a median age of 57 [interquartile ranges (IQR), 54–65] and equal gender distribution were conducted. Of the patients with diabetes mellitus (67.3%), the most common type of AVF with DASS was brachiocephalic AVF (73.7%). Overall, the prevalence of success was 82.0% (95%CI, 74.4%–89.6%) over 12 months (IQR, 1–40 months). Grade 3 ischaemia was the most common type of DASS (49.2%). Grade 4 had the worst outcomes compared with grades 2 and 3. The overall morbidity was 3% with no mortality. Overall, RUDI is an effective treatment for various grades of DASS and their longevity.