Proximalization Of Arterial Inflow Research Articles

Proximalization of arterial inflow for treatment of hemodialysis access-induced distal ischemia

ObjectiveHemodialysis access-induced distal ischemia (HAIDI) is a known complication of hemodialysis (HD) access. Distal revascularization and interval ligation (DRIL) is the preferred treatment for HAIDI by many surgeons. Proximalization of arterial inflow (PAI) is a promising alternative technique that, unlike DRIL, preserves the native arterial inflow. The purpose of this study is to report our experience with PAI on a series of 64 patients. MethodsThis is a single-center, retrospective cohort study of patients with both arteriovenous (AV) fistulas and grafts who underwent PAI for HAIDI from 2017 to 2023. A 4 × 7 tapered polytetrafluoroethylene (PTFE) graft was used to connect HD access inflow to the axillary artery in the majority of cases. The primary outcome of the study is resolution of HAIDI (complete, partial, or no resolution). Secondary outcomes include functional patency (primary and secondary) and 30-day complications following PAI. ResultsOf the 71 patients identified to have had PAI between May 2017 to August 2023, seven were lost to follow-up. In total, 64 patients were included, with an average age of 65 years (standard deviation, 15 years), 59.4% (38/64) female, and 37.5% (24/64) African American. The study population was notable for numerous comorbid conditions including 95.3% (61/64) hypertension; 50% (32/64) coronary artery disease; 79.7% (51/64) diabetes; and 43.8% (28/64) smoking history. Following PAI intervention for HAIDI, 55 of 64 patients (85.9%) experienced complete resolution of ischemic symptoms; five of 64 patients (7.8%) had partial resolution; two of 64 patients (3.1%) had no resolution, and two of 64 patients (3.1%) had unknown resolution. Primary patency at 1, 12, and 24 months was 94%, 81%, and 71%, respectively. Secondary patency at 1, 12, and 24 months was 97%, 87%, and 84%, respectively. The 30-day complication rate was 10.9% (7/64), with five of 64 (7.8%) thromboses, one of 64 (1.6%) thrombosis and infection, and one of 64 (1.6%) upper extremity swelling secondary to central venous stenosis (resolved with angioplasty of central venous system). Failure rate due to thrombosis at 12 and 24 months was 14% (9/64) and 15.6% (10/64), respectively. ConclusionsOur study, the largest case series of PAI to date, demonstrates that PAI is a reliable option for HAIDI intervention and has comparable safety and efficacy results to DRIL, despite the use of a synthetic graft. Furthermore, PAI has the added benefit of maintaining the native arterial pathway. Further investigation of PAI is warranted as a promising alternative to DRIL for HAIDI management.

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.

Risk Factors and Management of Hemodialysis Associated Distal Ischemia

A review of the Vascular Quality Initiative between 2011 and 2019. Hemodialysis-associated distal ischemia requiring intervention occurred in about 3% of patients (970/35,236) who underwent vascular access placement, although 17% developed mild ischemia not requiring intervention. Intervention included catheter-based approaches (41%), access ligation (23%), distal revascularization with interval ligation (20%), banding (13%), proximalization of arterial inflow (1.5%), and revision using distal inflow (1.4%). The median time to hemodialysis-associated distal ischemia was 7 weeks. Multivariate regression demonstrated that white race, female sex, peripheral artery disease, diabetes, prosthetic grafts, upper arm access, and target vein diameter greater than 4 mm were significantly associated with an increased risk for distal ischemia. Hemodialysis-associated distal ischemia complicates about 3% of cases and is more likely in white females with diabetes and arterial disease after upper arm prosthetic graft placement.

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.

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.

POS-562 ISCHEMIC DISTAL HAND STEAL SYNDROME : A RARE COMPLICATION OF AVF

Ischemic steal syndrome is a rare complication of arteriovenous fistula creation due to high blood flow in a low resistance vein and reversal of flow away from the higher resistance distal arterial bed into the vein. Several options including ligation of arteriovenous fistula, banding, proximalization of arterial inflow and distal revascularization and interval ligation (DRIL).

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.

VS10. Arteriovenous Fistula Banding for Steal Syndrome With Quantitative Data

Steal syndrome is a rare and difficult problem associated with fistula creation. There are several modalities in the literature discussing management of fistulas with steal syndrome. The most common of these include banding, distal revascularization with interval ligation procedures, proximalization of arterial inflow, and revision using distal inflow procedures. Although all of these procedures have been shown to work, they all have a significant failure rate, such as persistent steal or loss of access. One of the limitations of all of these techniques is that there are no quantitative data gathered during the procedure to ensure success of treatment. We propose a novel method for banding of fistulas to improve the success of this process by obtaining a distal arterial pressure during the banding process. https://www.jvascsurg.org/cms/asset/54d58bd1-ecaa-49bd-bea3-aeeaca3ae125/mmc1.mp4Loading ... Download .mp4 (137.81 MB) Help with .mp4 files Video

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.

Access-related hand ischemia and the Hemodialysis Fistula Maturation Study

Access-related hand ischemia (ARHI) is a major complication after hemodialysis access construction. This study was designed to prospectively describe its incidence, predictors, interventions, and associated access maturation. The Hemodialysis Fistula Maturation Study is a multicenter prospective cohort study designed to identify predictors of autogenous arteriovenous access (arteriovenous fistula [AVF]) maturation. Symptoms and interventions for ARHI were documented, and participants who received interventions for ARHI were compared with other participants using a nested case-control design. Associations of ARHI with clinical, ultrasound, vascular function, and vein histologic variables were each individually evaluated using conditional logistic regression; the association with maturation was assessed by relative risk, Pearson χ(2) test, and multiple logistic regression. The study cohort included 602 participants with median follow-up of 2.1years (10th-90th percentiles, 0.7-3.5years). Mean age was 55.1± 13.4 (standard deviation) years; the majority were male (70%), white (47%), diabetic (59%), smokers (55%), and on dialysis (64%) and underwent an upper arm AVF (76%). Symptoms of ARHI occurred in 45 (7%) participants, and intervention was required in 26 (4%). Interventions included distal revascularization with interval ligation (13), ligation (7), banding (4), revision using distal inflow (1), and proximalization of arterial inflow (1). Interventions were performed ≤7days after AVF creation in 4 participants (15%), between 8 and 30days in 6 (23%), and >30days in 16 (63%). Female gender (odds ratio, 3.17; 95% confidence interval, 1.27-7.91; P= .013), diabetes (13.62 [1.81-102.4]; P= .011), coronary artery disease (2.60 [1.03-6.58]; P= .044), higher preoperative venous capacitance (per %/10mm Hg, 2.76 [1.07-6.52]; P= .021), and maximum venous outflow slope (per [mL/100mL/min]/10mm Hg, 1.13 [1.03-1.25]; P= .011) were significantly associated with interventions; a lower carotid-femoral pulse wave velocity and the outflow vein diameter in the early postoperative period (days 0-3) approached significance (P< .10). Intervention for ARHI was not associated with AVF maturation failure (unadjusted risk ratio, 1.18 [0.69-2.04], P=.56; adjusted odds ratio, 0.97 [0.41-2.31], P= .95). Remedial intervention for ARHI after AVF construction is uncommon. Diabetes, female gender, capacitant outflow veins, and coronary artery disease are all associated with an increased risk of intervention. These higher risk patients should be counseled preoperatively, their operative plans should be designed to reduce the risk of hand ischemia, and they should be observed closely.

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.

Síndrome isquémico de la mano secundario a acceso vascular para hemodiálisis. Estrategias terapéuticas

Access-induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. The construction of an arteriovenous access results in a predictable decrease in the perfusion pressure distal to the anastomosis, which can result in ischemia if the compensatory mechanisms are inadequate. Because many of the signs and symptoms are nonspecific, the diagnosis can be aided in equivocal cases with non-invasive vascular laboratory studies. A digital/brachial index < 0.45 is suggestive of severe ischemic syndrome, and is usually associated with pain at rest and/or trophic lesions on the fingers. The aims of the treatments are to reverse the hand ischemia and to preserve the access. There are a variety of treatments, including correction of the inflow lesion, access ligation, limiting the flow through the access (banding), distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI), or proximalization of arterial inflow (PAI). The optimal choice should be based on hemodynamic mechanisms and severity of symptoms, in conjunction with the access type and patient comorbidities. A review of the underlying pathophysiology and treatment options will be presented. To date, the DRIL procedure has been the most consistently successful strategy. However, the particular circumstances of each case demand an individualization of treatment.

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.

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 Strategies for Access-Related Hand Ischemia

Access-related hand ischemia, commonly known as "steal syndrome," is one of the most challenging and worrisome complications for the access surgeon. The construction of an arteriovenous access results in a predictable decrease in the perfusion pressure distal to the anastomosis, which can result in ischemia if the compensatory mechanisms are inadequate. Several preoperative clinical features have been shown to identify patients at risk. The diagnosis of access-related hand ischemia is largely a clinical one that can be aided in equivocal cases with noninvasive vascular laboratory studies. The treatment goals are to reverse the hand ischemia and to preserve the access. There are a variety of different remedial treatments, including access ligation, correction of the inflow lesion, limiting the flow through the access, proximalization of arterial inflow, revision using distal inflow, and distal revascularization with interval ligation. The optimal choice is predicated on the timing and severity of symptoms in conjunction with the access type, its anticipated durability, patient comorbidities, distribution of occlusive disease, and availability of venous conduit. The distal revascularization with interval ligation procedure has emerged as our optimal treatment and reverses the ischemic symptoms and salvages the access in approximately 90% of the cases. It is incumbent on all access surgeons to be familiar with the management of access-related hand ischemia. A review of the underlying pathophysiology and treatment options will be provided along with our current treatment algorithm.

Proximalization of Arterial Inflow for the Treatment of Access-Related Steal Syndrome

Hemodialysis access-related arterial steal syndrome can result in serious complications, such as tissue loss and amputation. Several methods have been used to treat arterial steal syndrome, but controversy persists regarding the optimal technique. Here we present a case of arterial steal syndrome successfully treated with proximalization of arterial inflow (PAI). A 63-year-old man with a brachial-cephalic arteriovenous fistula (AVF) was admitted with complaints of coldness and pain in the left hand and fingers. Duplex sonography and angiography revealed arterial steal and occlusion of the distal radial artery. He was underwent PAI which included transsection of the AVF just distal to the previous anastomosis and attachment of the arterialized vein to a more proximal portion of the brachial artery with a 4-mm expanded polytetrafluoroethylene (PTFE) graft. Digital arterial flow was restored, and his symptoms subsequently were relieved. The AVF was well-functioning without any ischemic symptoms after 3-month follow-up.

Treatment strategies of arterial steal after arteriovenous access

Ischemic 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. Patients with ISS between June 2003 and June of 2008 at the University of Pittsburgh Medical Center were retrospectively reviewed. Demographics, type of AV access, management technique, and success of intervention were recorded. Success was defined as resolution of ISS symptoms while preserving access function. One hundred consecutive AV access procedures were reviewed for comparison. Data were analyzed using χ(2) test, Fisher's exact test, and Student's t test. The study was approved by our institutional review board. A total of 114 patients with ISS had a mean age of 65 years (range, 20-90 years), were predominantly female (66%), diabetic (61%), and with a brachial origin fistula (69%). Risk factors for ISS included coronary artery disease (CAD; P < .001), hypertension (P < .001), and tobacco use (P = .048). Women were noted to have a brachial origin access more frequently than men (odds ratio [OR], 3.1; P = .009). Forty-four patients with mild steal were observed. Seventy patients underwent 87 procedures. Procedures performed included ligation (n = 27), banding (n = 22), distal revascularization and interval ligation (DRIL; n = 21), improvement of proximal inflow (n = 9), revision using distal inflow (RUDI; n = 4), and proximalization of arterial inflow (PAI; n = 3). Early procedures (<30 days from the index fistula) were mostly ligation (50%) or banding (38%), while DRIL was the most frequent choice for late interventions (41%). Banding had a high failure rate (62%) and was the most common reason for reintervention (8 of 11, 73%) and DRIL had a better success rate than banding (P ≤ .05). In our current practice, 18% of patients had an AV fistula with the proximal radial artery (PRA) as the inflow source, while this type of fistula accounted for only 2% of all ISS patients. Ligation resolved symptoms in all patients, but the AV access was lost. Risk factors for development of ISS include CAD, diabetes, female gender, hypertension, and tobacco use. Among various options to treat ISS, banding has a low success rate and high likelihood for reintervention, while DRIL is particularly effective although not uniformly. Less invasive treatment options such as RUDI and PAI may be quite effective in treating ISS. Use of the PRA as the inflow source may decrease the incidence of ISS.