Dialysis-associated Steal Syndrome Research Articles

Dialysis-associated steal syndrome as a rare complication of arteriovenous fistula angioplasty

Abstract The angioplasty of arteriovenous fistulas (AVF) has become indispensable in preserving haemodialysis access. Though well-known complications, such as pseudoaneurysm formation and rupture, can occur, the incidence of severe dialysis-associated steal syndrome (DASS) following AVF angioplasty is low. We describe a patient with limited dialysis options who developed significant DASS following angioplasty of his AVF. After excluding flow-limiting causes of DASS, the patient underwent a successful Revision Using Distal Inflow procedure, redirecting blood flow to his distal arm. Subsequently, all ischaemic symptoms resolved. While effective surgical options are available for the management of DASS, preventive measures such as proper angioplasty balloon sizing remain key.

Measuring Peri-Anastomotic Pressure to Identify Patients at High-Risk for Dialysis Associated Steal Syndrome

Dialysis Access-associated Steal Syndrome (DASS) is one of the most serious complications of hemoaccess surgery. Treatment algorithms involve significant morbidity; a tool to reliably identify patients at risk who could benefit from interventions at time of operation would be useful. We present a strategy of using peri-anastomotic pressure (PAP) measurement to identify patients who may be at high risk of developing DASS. Patients who underwent dialysis access creation between January 1, 2018 and September 30, 2022 at our institution were reviewed. Beginning October 2019, we developed a strategy of measuring systolic pressure at the arterial anastomosis intra-operatively. A ratio of this value compared to the systemic systolic pressure was calculated. In patients believed to be high-risk for developing DASS based on clinical findings, selective banding of the access was performed intra-operatively to augment distal perfusion. Of 857 total patients, 36 (4.2%) developed clinically significant DASS, defined as requiring operative treatment, either intraoperatively or during follow-up (mean, 76 days; range, 0-602 days). DASS was more common for femoral-based accesses (6/12, 46.2%) compared to upper extremity accesses (30/840, 3.6%, p < 0.001). No patients who underwent radiocephalic arteriovenous fistula (AVF) or infraclavicular axillary arteriovenous graft construction developed DASS. There was no difference in DASS for upper extremity AVFs (20/576, 3.47%) vs. AV grafts (10/264, 3.79%, p = 0.82). 216 patients had PAP measured intra-operatively. Fourteen (6.5%) of these 216 patients developed DASS requiring intervention in follow-up. The mean PAP ratio of these 14 patients was 0.395 vs. 0.557 for the 202 patients who did not [CI 0.07-0.25, p = 0.001]. Seventeen patients who had low PAP ratio with poor distal perfusion underwent intra-operative banding, which improved mean PAP ratios from a mean of 0.33 to 0.58. Despite banding, 3 of these 17 (17.6%) patients in this high-risk subgroup went on to develop DASS postoperatively. The calculated mean PAP ratio in patients who either developed DASS post-operatively or underwent prophylactic banding intra-operatively was 0.37, which was significantly lower than the mean ratio of 0.57 in the control group (p = 0.001). Low PAP ratios (less than 0.50) identified patients at elevated risk for DASS, but prophylactic banding did not always prevent the occurrence of DASS in select patients. Because steal is a dynamic phenomenon, intraoperative conditions are not always going to reflect later adaptation. Nonetheless, PAP measurement may identify a subgroup warranting procedural modification or closer postoperative physiologic monitoring.

Successful Revision Using Distal Inflow for Dialysis-associated Steal Syndrome with Finger Gangrene

Successful Revision Using Distal Inflow for Dialysis-associated Steal Syndrome with Finger Gangrene

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.

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.

The efficacy of the secondary Extension Technique in the management of arterio-venous fistula-associated steal syndrome.

Dialysis-associated steal syndrome remains a difficult clinical scenario for vascular access surgeons. The ideal treatment would improve blood flow to the hand without compromising the fistula; however, most treatment options rarely allow for both. The study describes an innovative technique used in clinical practice over a 17-year period for the treatment of dialysis-associated steal syndrome. The procedure and long-term results are discussed. 27 patients with dialysis-associated steal syndrome were recruited over 17 years at two large UK University Teaching Hospitals and treated with the extension technique. All patients included were assessed for resolution of their symptoms, patency of the fistula and adequacy of needling. 27 patients were admitted with dialysis-associated steal syndrome and underwent surgery using the extension technique. Complete symptom resolution was seen in 26 of the 27 patients (96%), with improvements in pain, sensori-motor disturbance and temperature. All 26 patients had a patent fistula at 6-months' follow-up. At 12 months, 3 of 27 (11.1%) developed fistula thrombosis which could not be salvaged and 2 of 27 (7.4%) developed thrombosis successfully salvaged by fistulaplasty. Our study shows that the Extension Technique is an effective treatment method for dialysis-associated steal syndrome and results have demonstrated a high level of fistula patency and a low rate of complications. It has several advantages when compared with other established treatment methods and has the versatility to be used as a method for dialysis-associated steal syndrome prevention in high-risk groups as well as treatment.

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.

Long-term outcomes of the ‘primary extension technique’ in the prevention of Steal syndrome

To report our 13 years of experience with the 'primary extension technique' for the prevention of dialysis-associated steal syndrome. All diabetic patients undergoing upper arm autogenous elbow fistula formation using the primary extension technique between September 2001 and September 2014 at a single centre were included. At follow-up all patients were evaluated for patency, adequacy of needling and the presence or absence of steal symptoms. In primary extension technique, the fistula is formed by anastomosing the median cubital vein with the proximal radial or ulnar artery just below the brachial artery bifurcation. In total, 64 operations of the primary extension technique were included in this study. All patients were diabetic. Primary failure was 5%, follow-up 23-84 months. Nine patients (14%) developed cephalic vein thrombosis. In these cases, the basilic vein was successfully transposed to the existing fistula. In eight patients (12.5%), the cephalic vein required superficialisation. In three patients, the flow was preferentially into the basilic vein with poor maturation of cephalic vein. Of these three patients, there was a small proximal cephalic vein in one patient and stenosis in the other two patients. One patient who developed dialysis-associated steal syndrome is included in the results as they were listed for primary extension technique fistula formation but in fact did not have their fistula formed using primary extension technique. Instead, the anastomosis was formed proximal to the bifurcation of the brachial artery. Symptoms improved with revision of the fistula. Our 13-year experience demonstrates that the primary extension technique is a safe and effective procedure for fistula formation. Patency rates are comparable to brachio-cephalic and brachio-basilic fistulas and primary extension technique is effective in the prevention of dialysis-associated steal syndrome.

Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER): A Review of the Available Literature and Brief Overview of Alternate Therapies in Dialysis Associated Steal Syndrome.

Dialysis associated steal syndrome (DASS) is a relatively rare but debilitating complication of arteriovenous fistulas. While mild symptoms can be observed, if severe symptoms are left untreated, DASS can result in ulcerations and limb threatening ischemia. High-flow with resultant heart failure is another documented complication following dialysis access procedures. Historically, open surgical procedures have been the mainstay of therapy for both DASS as well as high-flow. These procedures included ligation, open surgical banding, distal revascularization-interval ligation, revascularization using distal inflow, and proximal invasion of arterial inflow. While effective, open surgical procedures and general anesthesia are preferably avoided in this high-risk population. Minimally invasive limited ligation endoluminal-assisted revision (MILLER) offers both a precise as well as a minimally invasive approach to treating both dialysis associated steal syndrome as well as high-flow with resultant heart failure. MILLER is not ideal for all DASS patients, particularly those with low-flow fistulas. We aim to briefly describe the open surgical therapies as well as review both the technical aspects of the MILLER procedure and the available literature.

Proximal radial artery arteriovenous fistula for hemodialysis vascular access

ObjectiveThis study reviewed our experience with proximal radial artery-based arteriovenous fistulas (PRA-AVFs) for hemodialysis vascular access, evaluating characteristics of the patients, functional patency, risk of steal syndrome, survival of the patient, and technical considerations. MethodsWe retrospectively analyzed our database of consecutive patients, identifying those individuals with a PRA-AVF created during a 12-year period. In addition to physical examination, all patients underwent ultrasound vessel mapping by the operating surgeon, identifying the PRA-AVF configuration and outflow target most likely to succeed. ResultsPRA-AVFs were created in 1396 individuals during the 12-year study period. The mean age was 59 years (standard deviation, ±15.9 years); 717 (51%) patients were women, 819 (59%) were diabetic, and 394 (28%) were obese. A transposition procedure was required in 400 patients, and 189 (47%) of these were completed in two-staged operations. Preoperative characteristics with a negative impact on PRA-AVF cumulative patency included female gender (hazard ratio, 1.90; 95% confidence interval, 1.37-2.65), obesity (hazard ratio, 1.92; 95% confidence interval, 1.40-2.65), and younger age. Dialysis-associated steal syndrome (DASS) requiring an intervention occurred in 39 (2.8%) patients, and 85% of these were diabetic. The most common procedures required to restore hand perfusion while preserving the AVF were banding and outflow branch ligation or coil occlusion to decrease access flow. DASS emerged spontaneously in 15 (1.1%) of the patients, and 24 (1.7%) individuals developed hand ischemia requiring intervention after fistulography with balloon angioplasty of the PRA-AVF anastomosis during the first years of the study period. Limiting angioplasty balloon size for such patients avoided these uncommon angioplasty-induced DASS events in later years. Primary, primary assisted, and cumulative (secondary) patency rates were 60%, 90%, and 93% at 12 months and 47%, 86%, and 91% at 24 months, respectively. Follow-up was 0.7 to 127 months (median, 25 months). ConclusionsPRA-AVFs offer excellent functional patency with low risk of dialysis access-related steal syndrome. The antecubital site has a wide range of venous outflow options for both direct PRA-AVFs and transposition procedures.

IP155. A Completely Endovascular Technique for the Treatment of Dialysis-Associated Steal Syndrome

IP155. A Completely Endovascular Technique for the Treatment of Dialysis-Associated Steal Syndrome

Dialysis-associated steal syndrome (DASS).

In this article, we will review the clinical symptoms of dialysis access steal syndrome (DASS), evaluation, treatment options, and our approach and treatment algorithm. We reviewed the literature discussing different aspects of DASS including its epidemiology, pathogenesis, clinical presentation, evaluation and management options. DASS is the most dreaded complication of access surgery. Although the incidence is low, all providers caring for dialysis patients should be aware of this problem. Symptoms can range from mild to limb threatening. Although various tests are available, the diagnosis of DASS remains a clinical one and requires thoughtful management to have the best outcomes. Multiple treatment options exist for steal. We present diagnostic evaluation and management algorithm.

Modified MILLER banding procedure for managing high-flow access and dialysis-associated steal syndrome.

Both high-flow vascular access (VA) and dialysis-associated steal syndrome are serious complications requiring a flow reduction technique. We adopted the minimally invasive limited ligation endoluminal-assisted revision (MILLER) banding procedure with some modifications to control the high blood flow and steal syndrome during VA procedures and retrospectively assessed the outcome. Seven patients with high-flow access (access flow >1400 ml/min) and five patients with steal syndrome (with pain, coldness, or cyanosis) were treated using the MILLER banding method. Flow volume of the brachial artery was monitored using Doppler ultrasonography during the banding procedure. In patients with steal syndrome, the finger probe of a pulse oximeter was attached to a finger on the ipsilateral side, and the peripheral oxygen saturation (SpO2) was monitored. In the high-flow group, the mean access blood flow (Qa) decreased from 2043 ± 463 ml/min (mean ± SD) to 1248 ± 388 ml/min (p<0.001). In the steal syndrome group, the SpO2 value improved in all steal syndrome patients after banding. Symptoms were almost relieved in two steal syndrome patients. The Qa in the steal group decreased from 997 ± 867 to 548 ± 376 ml/min (p = 0.12). The secondary patency rates of the high-flow and steal groups at 6 months were 83.3% and 50%, respectively. The MILLER banding procedure with intraoperative access flow monitoring is effective to treat high-flow VA and steal syndrome.

Evaluation of the role of distal revascularization with interval ligation (DRIL) and revision using distal inflow (RUDI) in treatment of dialysis associated steal syndrome

Objective: Dialysis-associated steal syndrome (DASS) is a complication that may occur in >4% of patients with arteriovenous fistula. The best treatment method for this condition is up till now controversial. Aim of the work: The purpose of this study was to evaluate two common procedures to treat this condition; Distal Revascularization with Interval Ligation (DRIL) or Revision Using Distal Inflow (RUDI) aiming at preservation of both the function of the fistula and the limb. Patients and methods: Fourteen patients having native brachiocephalic or brachiobasilic hemodialysis AV fistula complicated by dialysis associated steal syndrome (DASS), were randomly divided according to treatment method into DRIL and RUDI groups with 7 patients in each group. Patients with proximal or distal arterial disease and those with low-flow steal were excluded Short term access patency and limb salvage were set as primary endpoints. In all patients great saphenous vein was harvested from the thigh. Early post-procedural follow up and mid-term follow up were after one and three months. Results: From November 2011 to March 2013, 14 patients presented with (DASS). In DRIL group (7 patients), the mean age was 49.2 years, 4 females and 4 diabetics while in RUDI group (7 patients), the mean age was 52.3 years, 5 females and 7 diabetics. All fistulas were brachiocephalic and only one was brachiobasilic AVF in DRIL group. All patients in both groups presented with pain, pallor, coldness and cyanosis of the hand Stage III DASS {rest pain) was present in 2 cases of each group, whereas Stage IV small superficial ulcers were present in 3 vs 4 and digital gangrene in 2 vs. 1 in DRIL vs. RUDI respectively In group 1 (DRIL) technique; 5 patients (71.4%) had marked improvement of pain, cyanosis, capillary refill and coldness. Pallor improved in all cases. Distal pulses returned in 4 patients, remained weak in one patient and failed to return in 2 (28.6%). Closure of the access was necessary in 2 patients due to infection in one and due to risk of limb loss in the other; access patency was (71.4%) and limb salvage was (100%). In RUDI cases, pain, hand coldness, pallor and cyanosis greatly improved in all cases post-operatively. Distal pulses and capillary refill returned and became comparable to the healthy side in 6 patients (85 7%). Limb salvage and access patency were achieved in all cases (100%). Conclusion: RUDI procedure incorporates most of the advantages of other access and hand-preserving procedures. In contrast to DRIL procedure, it is the fistula that is placed at risk by ligation and revascularization, not the native arterial supply to the ischemic hand RUDI may become the procedure of choice for patients with dialysis-associated steal syndrome after a brachial artery-based arteriovenous fistula.

Volume Flow Measurements in Arteriovenous Dialysis Access in Patients with and without Steal Syndrome

Introduction. Dialysis associated steal syndrome (DASS) constitutes a serious risk for patients undergoing vascular access operations. We aim to assess the measured volume flow using ultrasound in patients with clinically suspected steal syndrome and determine differences in flow among types of arteriovenous (AV) access. Methods. Patients with permanent hemodialysis access with and without ischemic steal underwent duplex ultrasound (US) exams for the assessment of volume flow and quantitative evidence of hemodynamic steal. Volume flow was measured in the proximal feeding artery. Results. 118 patients underwent US of which 82 (69.5%) had clinical evidence of steal. Women were more likely to develop steal compared to men (chi-squared test P < 0.04). Mean volume flow in patients with steal was 1542 mL/min compared to 1087 mL/min (P < 0.002) in patients without evidence of steal. A significant difference in flow volumes in patients with and without steal was only seen in patients with a brachial-cephalic upper arm AV fistula (AVF) (P < 0.002). When comparing different types of access with steal, brachial-cephalic upper arm AVFs had higher volume flows than the upper extremity AV graft (AVG) group (P = 0.04). Conclusion. In patients with DASS, women were more likely to develop steal syndrome. Significantly higher volume flows were seen with brachial-cephalic upper arm AVF in patients with steal compared to those without. A physiologic basis of this US finding may be present, which warrants further study into the dynamics of flow and its relationship to the underlying peripheral arterial pathology in the development of ischemic steal.

バスキュラーアクセス関連スチール症候群に対する皮膚灌流圧測定の有用性

【背景・目的】スチール症候群の診断は自覚症状と他覚所見を統合して行うとされている. 重度の虚血症状は潰瘍や壊死または不可逆的な神経麻痺などを伴うため, 高い診断能力を有する客観的評価法が求められる. 下肢のperipheral arterial diseaseにおいて, 皮膚灌流圧 (SPP) の測定が有用であると報告されており, 治療方針の決定や予後の治癒能力の判断として臨床的に用いられている. 今回, 上肢におけるバスキュラーアクセス (VA) 関連スチール症候群に対して, SPPの診断能力を検討した. 【対象と方法】当院にて内シャントを有する患者106例を対象とした. VAの診察時にスチール症状の有無を問診し, Fontainの重症度分類によりStage I∼IVの4群に分類し, 症状なし群を加えて5群に分類した. SPPは第3指または最も症状の強い指にて測定した. 5群のSPPの平均値を算出した. また, 対象症例をスチール症状の有無により分類し, 累積相対度数によりカットオフ値を算出した. 【結果】対象症例の内訳は, スチール症状なし43例 (AVF : 24例, AVG : 19例), スチール症状あり63例 (AVF : 16例, AVG : 47例) であった. 各群の平均SPP値は, 症状なし群85.8±25.0mmHg (44例), Stage I群48.4±11.7mmHg (28例), Stage II群35.8±13.5mmHg (17例), Stage III群24.7±10.0mmHg (16例), Stage IV群17.3±2.4mmHg (3例) であった. 類積相対度数によるスチール症候群発生のカットオフ値は, 57.5mmHg (感度 : 87.1%, 特異度 : 95.3%, 陽性尤度比 : 18.2) であった. 【結語】SPPはスチール症候群の診断能力が高く, 同病態の客観的検査法として有用である.

Coil Embolization as a Treatment Alternative for Dialysis-Associated Steal Syndrome

Steal syndrome is a rare but serious complication of arteriovenous fistulas (AVF) created as well as the angioplasty technique used for its maturation and can have severe consequences if left untreated. Standard treatment options generally lead to loss of fistula access, although newer practices such as coil embolization are being utilized to conserve the AVF. Here we illustrate a case of a 65-year-old man with end-stage renal disease on dialysis, who had a Brescia-Cimino (radiocephalic) AV fistula created and subsequently underwent balloon-assisted maturation for an underdeveloped fistula. One month later, the patient presented with a cold thumb and index finger along with parasthesias in those digits and was treated with coil embolization of the distal radial artery while leaving the AVF functional. Steal syndrome and the novel treatment option of coil embolization are reviewed here.

Percutaneous Embolization of Hemodialysis Fistulas by AMPLATZER Vascular Plug with Midterm Follow-up

Purpose To determine the midterm technical and clinical results of endovascular occlusion of native hemodialysis fistulas with the use of the AMPLATZER Vascular Plug (AVP) I and AVP II. Materials and Methods Data from 21 patients who underwent endovascular occlusion of their native fistulas between March 2008 and October 2009 were retrospectively evaluated. The reasons for closing the fistulas were hyperdynamic heart failure (n = 2), venous aneurysm with skin ulceration and nipple formation with impending rupture (n = 5), central venous occlusion that could not be recanalized by an endovascular approach (n = 7), dialysis-associated steal syndrome (n = 2), and critical hand ischemia with a nonhealing ulcer or necrosis (n = 5). Results All fistulas were embolized successfully by the end of the intervention. No procedure-related complications were observed after the intervention. The follow-up time ranged from 5 months to 24 months, with a mean of 13.5 months. Conclusions The results of this study suggest that the AVP is a safe and effective device for the endovascular occlusion of hemodialysis fistulas in selected cases.

The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome

The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome

Simple and Durable Resolution of Steal Syndrome by Conversion of Brachial Artery Arteriovenous Fistulas to Proximal Radial Artery Inflow

Dialysis associated steal syndrome (DASS) is relatively uncommon but constitutes a serious risk for patients undergoing vascular access operations. We report two patients with DASS where brachial artery vascular access inflow was revised to the proximal radial artery for arteriovenous fistula (AVF) inflow. DASS was resolved in both patients with the permanent resolution of symptoms, in addition to the healing of ulcerations and ischemia. Both AVFs were immediately functional and durable.