Distal Revascularization-interval Ligation Research Articles

Risk Factors and Management of Hemodialysis Associated Distal Ischemia

Hemodialysis-associated distal ischemia (HADI) is an uncommon, but significant complication after hemodialysis access creation that might require additional intervention. This study examines the risk factors for HADI and compares the outcomes of the different treatment modalities. The Vascular Quality Initiative hemodialysis access (2011-2019) registry was reviewed. Patients were classified based on the occurrence of HADI requiring intervention or not, and their respective characteristics were compared. Multivariable logistic regression was used to identify independent factors associated with HADI. Kaplan Meier curves of secondary patency after different modalities of surgical revision were compared. There were 35,236 vascular access creations and 970 (2.75%) were complicated by HADI requiring intervention. Treatment was performed with access ligation in 224 patients (23%) and catheter-based techniques in 394 (41%). Open surgical revision consisted of banding in 127 (13%), distal revascularization interval ligation (DRIL) in 196 (20%), proximalization of arterial inflow (PAI) in 15 (1.5%), and revision using distal inflow (RUDI) in 14 (1.4%). Median time to HADI was 49 days (IQR 17 -91 days). Multivariate regression demonstrated that white race, female sex, peripheral artery disease, coronary artery disease, diabetes, post-procedure antiplatelets, prosthetic grafts, upper arm access, and target vein diameter greater than 4 mm were significantly associated with increased risk for HADI. When compared to procedures without HADI, access patency was decreased when revision (excluding access ligation) was performed (secondary patency at 12 months, HADI revision versus none: 89.0% vs. 92.4%, P <0.01). However, after multivariate Cox adjustment, revision for HADI was not independently significantly associated with access failure. HADI complicates 2.75% of hemodialysis access cases and is more likely in white females with diabetes and arterial disease after upper arm prosthetic graft placement. The patency of dialysis access does not seem to be negatively impacted by the various methods of surgical revision for HADI.

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.

SS06. Efficacy of Surgical Correction of Dialysis Access Steal Syndrome

Surgical options to treat vascular access-related steal syndrome include distal revascularization-interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. The efficacy of these individual modalities in symptom resolution has not been previously reported. The aim of this study was to compare efficacy of different surgical modalities for treatment of steal associated with arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs). Retrospective analysis was performed on adults diagnosed with steal syndrome after hemodialysis access creation who underwent revision of their dialysis access by a singular vascular specialty group within one integrated health care system. Patients <18 years, those with lower extremity accesses, and those with HeRO grafts (Merit Medical, South Jordan, Utah) were excluded. Data were obtained from the electronic medical record system and analyzed using SPSS software (IBM Corp, Armonk, NY). Patients with preintervention duplex ultrasound-confirmed steal were identified and further evaluated by access type (AVG or AVF). The primary end point was clinical symptom resolution. There were 257 patients who underwent surgical interventions for steal syndrome. Of these, 143 patients had a preoperative duplex ultrasound examination suggestive of steal syndrome, with 98 associated with AVF (68.5%) and 45 associated with AVG (31.5%). Our population included predominantly women (65.7%) and African Americans (53.8%), with a mean age of 63.2 years (23-90 years). Symptom resolution for the two groups is reported in the Fig. In the AVF group, there was a statistically significant difference for complete symptom resolution between DRIL, PAI, banding, and access ligation at 64.6%, 80%, 26.3%, and 100%, respectively (χ2 test, P = .001). For AVGs, there was no statistically significant difference in symptom resolution between different surgical modalities (χ2 test; P = .555). In patients with AVF-associated steal, efficacy of DRIL and PAI in symptom resolution was superior to banding with statistical significance. Whereas access ligation had a higher percentage of symptom resolution in this subset, it should be reserved for cases of severe disease or when other viable options are absent. For AVG, clinical judgment and symptoms should be used in guiding surgical treatment preferences for symptom resolution.

A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia

Access-related hand ischemia (ARHI) is a potentially limb-threatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival. A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe Society for Vascular Surgery grade 3 ARHI were included for analysis. A total of 2035 autogenous accesses were created during the study period, and 58 (3%) developed grade 3 ARHI. Of this cohort, RUDI was performed in 20 and DRIL in 21. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5years, and 54% of patients were female. Most patients had diabetes (86%) and symptomatic peripheral arterial disease (63%). The mean preoperative digital-brachial index was 0.25± 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Primary patency between the RUDI and DRIL cohorts at 12months (58%± 11% vs 55%± 12%) and 36months (51%± 12% vs 41%± 12%) were similar (P= .841). Cumulative secondary patency at 12months (84%± 8% vs 94%± 6%) and 36months (78%± 9% vs 86%± 9%) showed no significant difference (P= .398). Resolution of ischemic symptoms, including resolution or improvement in pain or healing ofischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P= .131). Survival for patients who underwent RUDI or DRIL procedures at 1 and 3years was 85% vs 86% (P= .948) and 55% vs 49% (P= .278). In this preliminary study, the RUDI demonstrated similar patency, symptom resolution, and survival compared with the DRIL for patients with severe ARHI. All-cause mortality after any procedure for severe steal syndrome is high, and the particular intervention for management of steal must account for anatomic-, patient-, and disease-related considerations.

Revision using distal inflow is a safe and effective treatment for ischemic steal syndrome and pathologic high flow after access creation

Ischemic steal syndrome (ISS) and pathologic high flow (HF) are a complications after hemodialysis access creation. Their 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 HF. We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April, 2010 to March, 2014. Data collection included demographic characteristics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. We performed 29 RUDI procedures in 28 patients (16 women, 12 men). Indications for surgery were pathologic HF in 13 and ISS in 19. Ten percent had previous banding for ISS or HF. Sixty-nine percent of patients had a history of diabetes. Fifty-two percent had a history of atherosclerotic disease. Mean time to intervention from creation was 40 months (range, 6-88 months). Accesses included 1 upper arm graft and 27 brachial artery-based fistulas. Outflow included 25 cephalic veins and 3 basilic veins. Distalization targets were 19 radial arteries and 10 ulnar arteries. Mean flow reduction was 1191 mL/min. Primary assisted patency at 1 year was 74%. Secondary patency at 1 year was 87%. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 69% and partial in 31%. RUDI is an effective and durable treatment of ISS and HF comparable with reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and banding. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.

Intervention for access-induced ischemia: which option is the best?

Access-induced ischemia is a rare but important surgical complication with potentially devastating long-term results. The question remains which therapeutic option is the best for the different forms of ischemia. A review of the literature concerning access-induced ischemia (classification, treatment) was performed; furthermore, our own experience of more than 300 cases with ischemia was discussed. There are four different stages of dialysis access-induced ischemia syndrome (DAIIS) that need adequate treatment: stage I conservatively, stage II fistula banding, stage III proximalization operation or distal revascularization interval ligation and stage IV closure of the access. According to the many publications and to our own experience, there are good therapeutic options for many of the patients with DAIIS. However, in case of extended lesions/gangrene, closure of the access should be discussed in time before major amputation becomes necessary.

Aggressive Costoclavicular Junction Decompression in Patients with Threatened AV Access

A substantial number of patients with threatened arteriovenous (AV) access are found to have stenoses at the costoclavicular junction (CCJ), which frequently are resistant to angioplasty and stenting. We believe that stenoses in this location will not resolve unless bony decompression is performed to relieve the extrinsic compression on the vein. This article describes our short- to medium-term results following such decompression in patients with failing fistulae. We reviewed a prospectively maintained database to identify all patients with threatened AV access operated on for stenoses at the CCJ. Pre- and postoperative course along with long-term follow-up were analyzed. Between July 2012 and December 2013, 24 patients with threatened access were operated on for CCJ stenoses at our institution. Fifteen had highly dysfunctional AV fistulae otherwise felt to need ligation, 10 had significant arm and/or head swelling, and 3 required access but had no contralateral options. In 6 patients, the subclavian vein was occluded and 18 stenotic; 5 of these had stents in place through the CCJ. Decompression was performed via claviculectomy in 3 patients, 2 of whom underwent reconstruction (one jugular vein, one prosthetic bypass) and 1 was stented. The other 21 patients underwent first rib resection, 20 via an infraclavicular exposure and 1 via a supraclavicular rib resection. A variety of interventions were performed in the arm, including aneurysm plication, cephalic to deep bypass, one prophylactic distal revascularization interval ligation, and several primary fistulae. 30-Day mortality was minimal: there was one significant hematoma and one hemothorax in a patient who underwent on-table thrombolysis and there were no deaths or cardiac, neurologic, or other significant morbidity. Median length of stay was 2 days. At follow-up up to 20 (median 10) months, 4 patients died of unrelated causes and 1 patient undergoing central reconstruction with prosthetic bypass required excision of this for infection and ligation of his fistula. Two other fistulae failed. One-year assisted primary patency of the fistula was 85%, and of the central bypass, 89%. At last follow-up, the index arm continued to be used for access in 85% of patients, and overall survival was 68%. Virtually all patients experienced dramatic symptom relief. In this group of high-risk patients whose access was judged otherwise nonsalvageable, excellent symptom relief and long-term fistula and ipsilateral arm use can be achieved with aggressive decompression of the bony CCJ followed by endovascular intervention as needed.

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

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.

Hemodiyaliz amaçlı arteriyovenöz fistüllerde distal hipoperfüzyona bağlı iskemik sendrom

Background: This study aims to evaluate the reasons for steal syndrome and preventive and therapeutic modalities. Methods: Thirty-six patients (23 males, 13 females; mean age 58.3 years; 43 to 77 years) who were treated in our cardiovascular outpatient clinic between January 2012 and September 2012 were retrospectively analyzed. Results: Nineteen of the patients were diabetic (52.7%). Fistulas were located in the antecubital region in 21 patients (58.3%), while others were located in the distal forearm. We performed distal revascularization interval ligation in four patients (11.1%), banding in eight patients (22.2%), plication of anastomosis and dilated venous segment in four patients (11.1%), interposition of 6 mm PTFE graft in five patients (13.8%) and ligation of distal radial artery in eight patients (22.2%). Ligation of radial artery and lateral branches with banding was administered in four patients (11.1%). Three patients (8.3%) underwent revision surgery by using distal inflow. None of the patients had loss of thrill following the procedure. No catheter was required except for one patient. The mean follow-up was 10.9 months (range 1-28 months). The procedure failed in five patients (13.8%). The complaints were completely recovered in 31 patients. Conclusion: We conclude that the continuity of dialysis can be highly sustained in patients with steal syndrome due to dialysis, maintaining the current arteriovenous fistulas through appropriate revision techniques.

Tratamento da síndrome de roubo de fístula arteriovenosa pela técnica de revascularização distal e ligadura arterial: relato de três casos

Fístulas arteriovenosas para hemodiálise podem apresentar complicações a longo prazo. Entre as complicações mais raras, há a isquemia distal por síndrome de roubo. Os autores relataram a experiência de três casos de pacientes portadores de fístulas braquiocefálicas, em funcionamento por longo prazo e que evoluíram com isquemia crítica do membro, sem resposta com tratamento clínico. Com o intuito de tratar esta afecção e preservar o acesso vascular, optou-se pela realização da revascularização distal interposta por ligadura arterial. Devido à raridade dos casos, relatou-se a experiência e apresentou-se uma revisão de literatura.

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.

Invited commentary

This study from the University of Pittsburgh addresses an important clinical problem after hemodialysis access creation: the ischemic steal syndrome (ISS). It is one of the largest series in the literature.1Gupta N. Yuo T.H. Konig G. Dillavou E. Leers S.A. Chaer R.A. et al.Treatment strategies of arterial steal after arteriovenous access.J Vasc Surg. 2011; 54 (in press)Google Scholar The pathophysiology of ISS is worth reviewing. The magnitude of blood flow through an arteriovenous fistula is a function of the diameter of both the fistula and the donor artery. Fistulas are classified by the fistula diameter relative to that of the donor artery. Small fistulas are defined as having a diameter <75% of the diameter of the inflow artery. In small fistulas, the primary determinant of the magnitude of fistula flow is fistula resistance, which varies with the fourth power of the diameter. The natural history of small fistulas is thrombosis. Large fistulas have a diameter >75% that of the donor artery, and the magnitude of blood flow tends to be independent of fistula resistance and diameter. In large fistulas, flow is determined primarily by the relative resistances of the peripheral vascular bed, the donor artery, and the collateral circulation. Most surgically created fistulas are of the large variety in order to provide sufficient blood flow (approximately 600 ml/minute) for dialysis.2Wixon C.L. Hughes J.D. Mills J.L. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access.J Am Coll Surg. 2000; 191: 301-310Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 3Wixon C.L. Mills J.L. Berman S.S. Distal revascularization-interval ligation for maintenance of dialysis access and restoration of distal perfusion in ischemic steal syndrome.Sem Vasc Surg. 2000; 13: 77-82PubMed Google Scholar Nearly all surgically created fistulas create physiological steal; ISS results when distal arterial perfusion is inadequate to meet tissue metabolic requirements.2Wixon C.L. Hughes J.D. Mills J.L. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access.J Am Coll Surg. 2000; 191: 301-310Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar Thus, it is no surprise that banding, which increases fistula resistance, is unlikely to achieve the dual goals of ISS treatment (ie, preservation of the access and relief of the ischemia). In this series, banding had poor outcomes. Nineteen percent of fistulas thrombosed after banding, and 48% of patients had persistent ischemia; 73% of reinterventions were performed in patients who underwent banding. Distal revascularization and interval ligation (DRIL) had a statistically better success rate than banding (P ≤ .05) and was effective in resolution of ISS in 90% of patients. DRIL remains the procedure of choice for treatment of ISS.4Knox R.C. Berman S.S. Hughes J.D. Gentile A.T. Mills J.L. Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access.J Vasc Surg. 2002; 36: 250-256Abstract Full Text PDF PubMed Scopus (153) Google Scholar I would urge future investigations of ISS to include hemodynamic data (digital arterial pressure measurements with and without fistula compression), which in my view, are essential to confirm the diagnosis and quantify severity.2Wixon C.L. Hughes J.D. Mills J.L. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access.J Am Coll Surg. 2000; 191: 301-310Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar While hemodynamic data were not routinely collected in this series, it is interesting to compare pre- and postoperative hemodynamics for those in whom they were available. Following the DRIL procedure, digital pressures increased from 43 to 75 mm Hg; after banding, the corresponding increase was only from 33 to 44 mm Hg. This difference was statistically significant and likely accounts for the failure of a substantial number of banded patients to improve. The authors report some experience with revision using distal inflow (RUDI) and proximalization of arterial inflow (PAI). While the reported results were excellent, patient numbers were low. These procedures likely work in a manner analogous to the DRIL procedure, by altering relative resistances (either by adding length or reducing donor artery diameter) rather than by increasing fistula outflow resistance. Such procedures, based on the physiology of ISS, are most likely to succeed. This is a well-written study of ISS. Hopefully, it will lay banding to rest. Future investigations, especially with the newer RUDI and PAI procedures, should include hemodynamic data and sufficient follow-up to allow comparison with the well-established DRIL procedure. Treatment strategies of arterial steal after arteriovenous accessJournal of Vascular SurgeryVol. 54Issue 1PreviewIschemic steal syndrome (ISS) associated with arteriovenous (AV) access is rare but can result in severe complications. Multiple techniques have been described to treat ISS with varying degrees of success. This study compares the management and success associated with these techniques. Full-Text PDF Open Archive

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.

Pre- and Postprocedure Duplex Evaluation of Distal Revascularization-Interval Ligation Procedure: A Case Study

Introduction Duplex ultrasound is a valuable modality for the assessment of hemodialysis access function. A potential complication of hemodialysis access is arterial steal, which occurs when venous outflow exceeds the capacity of the inflow artery, and flow in this distal artery becomes retrograde, stealing blood flow from the hand to the fistula site. A potential condition resulting from arterial steal is hand or digit ischemia. Distal revascularization-interval ligation (DRIL) procedures can be used to “bypass” the fistula or graft site and deliver blood to the hypoperfused hand. Presented is a case of an arterial steal with severe hand ischemia that was alleviated by a DRIL procedure. Case Study A 69-year-old woman presented to the vascular laboratory with an ischemic right hand and digital ulcer distal to a brachial-axillary arteriovenous graft (AVG). Duplex ultrasound was performed of the right upper-extremity inflow arteries, AVG, and outflow veins. Ipsilateral brachial, radial, and ulnar artery waveform analysis for direction of flow was performed with and without AVG compression. The evaluation revealed significant arterial ischemia that returned to normal after manual compression of the AVG. The patient underwent a DRIL procedure after the pre-op duplex evaluation. Postprocedural duplex evaluation revealed patent inflow and outflow vessels, patent graft, and bypass (DRIL) with antegrade flow in the brachial and radial arteries and no change of flow with manual graft compression; clinically, the patient had a healing ulceration of the digit. Conclusion Duplex ultrasound for hemodialysis access should not only be used to evaluate for patency of the fistula or graft but should include assessment for ischemia and/or steal. This case demonstrates the importance of the assessment of the distal arterial segments including digital waveforms, and the use of manual compression to complete the hemodialysis access evaluation. DRIL procedures can potentially correct arterial steal while preserving access function.

Combined Femoral Vein Transposition and Iliac Vein to Suprarenal Vena Cava Bypass as a Last Resort Dialysis Access

Patients undergoing hemodialysis are known to develop central venous occlusion and exhaust all options for vascular access to upper extremity sites; therefore, creating and maintaining vascular access is paramount in such patients. The present case report describes the condition of a 34-year-old woman with failed upper extremity access, frequent catheter-related issues, and multiple central venous occlusions. As a last resort, access to the lower extremity was pursued as follows: an inferior vena cava bypass was combined with a right femoral transposition fistula and a distal revascularization interval ligation procedure. This complex procedure that was carried out for the purpose of vascular access is a unique, albeit aggressive, surgical solution that resulted in autologous vascular access with a 6-month patency and also served to improve the quality of life in the seemingly hopeless case.

Arterial Pressure Gradient of Upper Extremity Arteriovenous Access Steal Syndrome: Treatment Implications

Treatment options after arteriovenous fistula (AVF) associated steal include ligation, banding, and distal revascularization-interval ligation (DRIL). The purpose of this study was to evaluate the arterial pressure gradients in upper extremity steal syndrome. Preoperative arteriography and sequential intra-arterial pressure readings were performed on consecutive AVF patients with hand ischemia. Analysis of variance (ANOVA) with repeated measures analyzed intersubject comparisons, and post hoc analysis identified anatomic locations with highest inflow pressures. Nine patients presented with ischemic hand symptoms after AVF. Pullback arterial pressure measurements revealed gradual increases in systolic and mean pressures as the catheter position was moved proximally from the AVF anastomosis. Post hoc analysis after ANOVA revealed higher axillary artery systolic pressure compared to proximal brachial artery (153 vs 116.8, P = .007). AVF-related steal syndrome decreases arterial inflow pressure of the affected extremity more proximally than previously thought. When performing a DRIL procedure, consideration should be given to placing the anastomosis as proximally as possible.

Dramatic event after acute ischaemic steal syndrome following arm arteriovenous fistulae.

A 74-year-old man with hypertension and peripheral vasculopathy history was admitted to our hospital to start renal substitutive treatment with haemodialysis through a functioning right humeral-cephalic arteriovenous fistula. In the first week after starting haemodialysis, the patient presented signs of distal ischaemia in the second and third fingers. A fistulography confirmed distal steal by arteriovenous fistulae without distal perfusion of palmar arch, even with the fistula occlusion manoeuvre (Figure 1). We decided to close the fistulae, and we implanted a tunnelized jugular catheter for haemodialysis. After fistula ligation, the pain decreased, but 5 days later, the ischaemic lesions progressed involving the first and fourth fingers, and a palmar ulcer appeared (Figure 2). Finally, amputation of the hand was required. Fig. 1 Fistulography showing a poor palmar arch perfusion. Fig. 2 Severe ischemia of the right hand due to steal by the arteriovenous fistulae. Arteriovenous fistula in the arm is commonly related to physiological steal with a reverse flow in the artery distal to the fistula. This change in the blood flow of the extremity can lead to distal ischaemia; however, hand ischaemia or infarction is rare. The ischaemic steal syndrome is usually a result of arterial disease proximal or distal to the fistula. It is manifested by pain, weakness, pallor, and, in severe cases, ulceration and tissue loss. Severe ischaemia, requiring reintervention, has an incidence of 4%, although some degree of ischaemia-causing pain or paresthesias occurs in 10–20% of patients following access construction [1]. Pathophysiology may be on the basis of inadequate arterial collateral inflow due to occlusive disease, particularly involving the medium-sized vessels, or high flow in a fistula exceeding the inflow capacity in the absence of intrinsic occlusive disease of the inflow arteries [2]. Operative techniques for correcting steal include arteriovenous fistula ligation, percutaneous transluminal angioplasty, banding or restrictive procedures, and distal revascularization interval ligation [3,4]. Intervention for ischaemic steal syndrome successfully resolves ischaemia in 80–95% of patients, and although fatal outcomes are rare, these can occur as was the case in our patient. Conflict of interest statement. None declared.

Distal Revascularization— Interval Ligation (DRIL) for the Treatment of Dialysis Access Steal Phenomenon

The incidence and prevalence of end-stage renal disease continues to grow, even as treatments improve. The vascular steal phenomenon is an infrequent but often debilitating complication of dialysis access placement, and management can be difficult. A specific technique called distal revascularization—interval ligation, or the DRIL procedure, has been used with success in managing this problem. Anatomically, the site of the steal is bypassed, and the native vessel just distal to the steal site is ligated, making duplex sonography evaluation complex. An examination algorithm is presented, with illustrative examples, to assist the sonographer in evaluating dialysis access patients when they have had the DRIL procedure. The algorithm is based on breaking the study into more easily managed components: (1) duplex sonographic evaluation of arterial inflow and runoff as well as venous outflow, (2) duplex sonographic evaluation of the bypass graft, (3) duplex sonographic evaluation of the fistula/shunt, and (4) physiologic testing of flows to the hand and digits. Based on the knowledge of the pathophysiology of steal and the configuration of the DRIL reconstruction, a complete and accurate evaluation can be performed with confidence.

Plication as Primary Treatment of Steal Syndrome in Arteriovenous Fistulas

Conclusion: Plication is a simple alternative to management of steal syndrome after construction of an autogenous arteriovenous fistula. Summary: There is always some steal in patients after creation of an arteriovenous fistula for hemodialysis. Pathologic steal is uncommon but can produce devastating complications. Overall incidence is 1% to 9%. In many practices, the distal revascularization-interval ligation (DRIL) procedure has become the preferred method to treat steal syndrome. However, this operation requires a new bypass and results in ligation of the brachial artery distal to the fistula. Although plication of an arteriovenous fistula is a known technique for dealing with steal syndrome, it is rarely reported. In this article, the authors describe their technique, in a small number of patients, for plication of arteriovenous fistulas associated with clinically significant steal. Seven patients were treated with plication. Their symptoms included paresthesia, coolness, and pain in the hand and fingers. No one had ulceration. In six of seven patients, a radial artery pulse returned with compression of the fistula. Plication was performed using a Satinsky clamp as a guide for the degree of plication, with the vein narrowed by a running horizontal mattress suture of 6-0 polypropylene. The length of vein plicated was approximately 1 cm, and the extent of plication was determined by return of a palpable pulse at the wrist or a change from monophasic to a biphasic distal Doppler signal. If the Doppler signal did not improve, the Satinsky clamp was reapplied and the plication repeated, further narrowing the plicated length of the fistula. The radial pulse returned postoperatively in six of seven patients. Mean follow-up was 9 months. At 13 months, symptoms had recurred in only one patient, the patient in whom the radial pulse did not return. Comment: Many patients with steal syndrome can be managed by observation. The inflow vessel dilates, and symptoms may resolve within a few days to weeks. A basic principle of surgical therapy is to perform simple procedures that are effective in preference to more complex procedures. DRIL procedures are effective for steal, with an 83% to 100% success rate; however, they are major operations, and the brachial artery is ligated. This study serves as a reminder that simple plication may be an effective treatment for steal syndrome and should be considered as an alternative treatment for steal before performance of a DRIL procedure.

Arteriovenous Fistula Construction Using Femoral Vein in the Thigh and Upper Extremity: Single-Center Experience

The objective of this study was to determine the outcome of femoral vein (FV) access as either a FV thigh transposition or upper extremity FV translocation. This is a retrospective review of all end-stage renal disease (ESRD) patients who underwent FV access at the University of Colorado Health Sciences Center from December 2004 to May 2007. Demographics, number of prior access procedures, FV dialysis access procedure, periprocedural complications, mean follow-up, secondary access-related procedures, and access function were recorded. Complications were subdivided into FV harvest site- and ischemia-related. Nineteen patients underwent FV access during the study period: 10 underwent FV thigh transpositions and nine underwent upper extremity FV translocations. The median number of prior access procedures was two. The median hospital stay was 3 days, and there were no perioperative deaths. Eight patients had FV harvest site complications: six lymphoceles, one AVF infection requiring ligation, and one compartment syndrome requiring fasciotomy. Three (16%) patients had ischemic complications: one required ligation of the AVF and two required distal revascularization interval ligation. Seventy-nine percent of patients had a functioning access at a mean follow-up of 6 months (range 23 days to 3 years). Four FV arteriovenous accesses required one or more endovascular procedures to maintain function at 12 months. The use of FV access in ESRD is durable at intermediate follow-up but has significant morbidity. FV access should be reserved for good-risk patients who have exhausted other autogenous options.