Steal Syndrome Research Articles

Endovascular treatment and morphology typing of chronic ostial occlusion of the subclavian artery.

Chronic obstructive lesions of the subclavian artery (SCA) often result in subclavian steal syndrome, which leads to arm claudication, transient cerebral ischemia, and other serious complications. The lesions are classified as stenosis and occlusion, according to the degree of obstruction. Unlike totally occlusive lesions, including ostial occlusions, stenotic lesions have an excellent technical success rate. In the present study, ostial occlusions were classified into 4 types according to their angiographic appearance. A total of 8 patients (6 male, 2 female) with SCA occlusions were treated with percutaneous transluminal angioplasty and stenting over a 4-year period. Mean patient age was 65.6 years (range, 60-72 years). In total, 9 self-expanding and 1 balloon-expandable stent were implanted at the ostia of the SCA in 7 of the patients. One female patient did not undergo stenting. Bleeding at the access site was noted in 2 patients and was controlled by gauze pressure. The patient that did not undergo stenting was lost to follow-up with symptoms of a transient ischemic attack at 3 months. The mean follow-up time for the remaining 7 patients was 15.7 months (range, 1-36 months). No ischemic symptoms, neointimal hyperplasia, or restenosis was observed in these patients. The transfemoral artery operation approach is preferred for rat-tail and peak type occlusions, whereas the dual approach involving both femoral and radial arteries is preferred for hilly and plain type occlusions. The angiographic morphology typing used in the present study may serve as a reference to decide upon the interventional operation strategy to be used for improving the technical success rate.

Early use of autogenous arteriovenous fistula in patients with urgent hemodialysis.

This study was designed to evaluate the long-term patency rate and complications associated with early use of the autogenous forearm arteriovenous fistula (AFAVF) in patients needing urgent hemodialysis. The clinical data of all patients undergoing AFAVFs for hemodialysis access between June 1996 and June 2016 were retrospectively evaluated. The primary and secondary patencies were estimated using the life table method. A total of 104 AFAVFs were created for 102 patients. All patients had entered hemodialysis when fistulas were constructed. The mean time to the first cannulation of the AFAVF was 17.33±4.60 (5-27days). Four AFAVFs (3.8%) became occluded within 30days of creation of the access, and five AFAVFs (4.8%) had hematomas after cannulation. There were no cases of infection of the wound or steal syndrome or prolonged arm edema. The primary patency rate was 77.81% at 1year, 73.05% at 2years, 64.64% at 3years, 60.75% at 5years and 47.48% at 10years. The secondary patency rate was 96.78% at 1year, 95.18% at 5years and 85.81% at 10years. In this study, the patency rates following the early use of the AFAVFs were not inferior to the previously reported patency rates in the literature. For patients entering hemodialysis with an inserted central catheter, the early use of the AFAVFs decreases the complications associated with catheters.

Forearm versus upper arm grafts for vascular access.

Forearm and upper arm arteriovenous grafts perform similarly in terms of patency and complications. Primary patency at 1 year for forearm arteriovenous grafts versus upper arm grafts ranges from 22%-50% versus 22%-42%, and secondary patency at 1 year ranges from 78%-89% versus 52%-67%), respectively. Secondary patency at 2 years, ranges from 30%-64% versus 35%-60% for forearm and upper arteriovenous graft, respectively. Ample pre-operative planning is essential to improved clinical success and the decision to place a graft at one location versus the other should be based solely on previous access history, physical exam, appropriate venous imaging, and other factors that make up the clinical picture. Operative implant strategies and risk of complications are very similar between the two configurations. Postoperative ischemia due to steal syndrome is a potential complication that requires immediate attention. Utilization of the proximal radial or ulnar artery for inflow for the graft can minimize risk of clinically relevant 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.

Early cannulation graft Flixene™ for conventional and complex hemodialysis access creation.

The Flixene™ (Atrium™, Hudson, NH) is a trilaminate composite polytetrafluoroethylene (PTFE) graft that allows access within 72 hours. We evaluate our initial experience with this device for conventional and complex hemodialysis access creation. Retrospective review in end-stage renal disease (ESRD) patients who underwent access creation with Flixene from January 2013 to July 2014. For our analysis, the patients were divided in two groups: those with complex access configurations tunneled in the chest and/or abdominal wall (thoraco-abdominal wall access [TAWA]), and those tunneled in conventional sites (extremity access [EA]). Patient's demographics, indications, complications, reinterventions, patency rates and factors influencing outcomes were evaluated. In 19 patients (54% men; mean age 44 years ± 18), 24 grafts were implanted, (13 EA [54%] vs. 11 TAWA), all patent after surgery. Central venous occlusive disease (CVOD) was present in all patients with TAWA and in 7/13 (54%) EA patients (p = 0.016). Early cannulation (within 72 hours) was successful in 12 EA and 5 TAWA grafts (p = 0.044). Complication rates including infection, thrombosis, bleeding and steal syndrome were 8/11 (73%) in TAWA and 5/13 (38%) in EA (p = 0.02). At 12 months, primary patency rates for EA and TAWA were 25% and 41%; secondary patency rates were 55% and 41%, respectively. Early cannulation (EC) grafts are viable alternatives for conventional and complex access creation that allowed early cannulation (<72 hours) in 17 (70%) of our cases. Primary and secondary patency rates at 12 months were equivalent to data reported on ePTFE grafts.

Current understanding and management of splenic steal syndrome after liver transplant: A systematic review.

Splenic steal syndrome (SSS) is a condition that can occur after orthotopic liver transplant (OLT). However, limited information is available about this condition. A systematic literature search of studies performed through May 2016 was conducted to identify reports of angiographically confirmed SSS and its variants. All of the factors relevant to this disorder were collected and analyzed. A total of 219 cases of SSS and its variants were identified. The condition occurred in 4.7% of patients after OLT, and 93.7% of cases were diagnosed within the first 2 months after OLT. Conventional arteriography demonstrated nonocclusive hepatic artery hypoperfusion in all affected patients. Abnormal liver function was the most common clinical presentation, reported in 71.9% of cases. Less common presentations included thrombocytopenia, acute graft failure, and persistent ascites. On Doppler ultrasound, a high resistance index of the hepatic artery was present in 84.1% of patients. Increased spleen volume (≥829 mL) before OLT was suggestive of a potential risk for SSS. Splenic artery embolization (SAE) was performed in 94.7% of cases; this procedure immediately reversed flow abnormalities on Doppler ultrasound and improved liver function tests in 96.3% of cases. The risk factors and potential etiologies of SSS remain largely unknown. Future studies should investigate the possible role of pre-OLT portal hypertension and portal hyperperfusion after OLT in the development of this syndrome. Collecting intraoperative hemodynamic data and performing Doppler ultrasound screening after OLT could potentially help clinicians to identify patients at high risk of arterial hypoperfusion and prevent potential complications from hepatic artery hypoperfusion.

Subclavian artery stenting for coronary-subclavian steal syndrome.

To evaluate the safety and feasibility of subclavian artery stenting for coronary-subclavian steal syndrome (CSSS). CSSS is a rare cause of myocardial ischemia due to ipsilateral subclavian artery stenosis in patients who have undergone coronary artery bypass graft. However, current knowledge of the optimal therapy for CSSS is limited. The clinical data of 37 patients (33 male; mean age 65 ± 6 years) with CSSS who had undergone subclavian artery stenting between April 2007 and December 2015 were analyzed. The time elapsed between bypass surgery and the diagnosis of CSSS was 6.3 ± 4.3 years (median 5.2 years, range 1.3 months to 17.8 years). The technical success rate was 97.3% (100% for stenosis, 85.7% for occluded lesions). One patient experienced a transient ischemic attack; a second patient developed flow-limiting dissection involving the ostium of the internal mammary artery; and a third patient had a puncture site hematoma. The mean stenosis of target lesions decreased from 87.6 ± 10.6% to 5.9 ± 5.0% immediately after the procedure. A total of 35 (94.6%) patients were discharged with a complete remission of myocardial ischemia. During a follow-up of 44 ± 32 (range 6-112) months, no patient suffered from stroke or myocardial infarction. Stent-restenosis related unstable angina developing in one patient at 36 months and in another patient at 11 months, both of whom were relieved after balloon angioplasty and remained asymptomatic until the last follow-up. Subclavian artery stenting is feasible and safe in patients with CSSS, with a low incidence of perioperative complications and stent restenosis rate. © 2017 Wiley Periodicals, Inc.

Distal Revascularization and Interval Ligation “DRIL” Procedure in Steal Syndrome Management in Hemodialysed Patients

Background: Steal syndrome complicates access in an increasing number of chronic renal failure (CRF) patients. Surgical procedures as (banding or fistula ligation) to manage this issue have proved to be entirely unsatisfactory because of loss of the recently created access through ligation or attempted salvage by increasing resistance within the fistula. Objective: To determine the results of DRIL technique in treating steal syndrome in CRF patients. Methods: A retrospective study (2015 to 2017) was conducted on 49 patients complaining of steal syndrome (out of 1200 CRF patients) with ages ranged from 35 to 71 years (mean=57 years) after obtaining written informed consent. Twenty nine patients were females (59.1%) and 20 (40.9%) were males. These subjects have undergone DRIL procedure in Vascular Surgery Departments, Qena and Assiut University Hospitals. Pre-procedural angiography was performed in most cases. Patient characters, risk factors, types of fistulae and indications for surgery were listed. The clinical outcomes of the procedure, Arteriovenous Access (AVA) and bypass graft patency were determined as well. Results: The AVA, which led to steal syndrome, was proximally located in the arm (brachiocephalic in 14, brachiobasilic in 14, and prosthetic brachio-axillary in the remaining 21 patients). Steal symptoms comprised hand ache, neurologic deficiency and gangrenous ulcerations. The procedure was technically effective in all subjects. Prompt and total pain release was accomplished in 43 (87.7%) of the 49 patients. One patient (2%) with gangrene later underwent transmetacarpal amputation. No patient required hand amputation. During follow-up (range 0.5 ± 17 months) hemodialysis was carried out continuously using the AVA in 40 subjects. AVA thrombosis had happened in 8 (16.3%) subjects only post DRIL. Significant difference was found between diabetes and occurrence of steal syndrome (p value<0.05) and between type of fistula (prosthetic AVF) and steal syndrome as well (p value<0.05). Six subjects died from other causes not related to the performed procedure. Conclusion: In certain subjects DRIL technique is a secure and efficient method to manage steal syndrome. AVA durability is not influenced by this procedure. Pre-operative angiography pre and post AVA manual compression is essential for adequate patients’ selection in which benefit will be gained mostly by the performed procedure.

КЛИНИЧЕСКИЙ СЛУЧАЙ ЭНДОВАСКУЛЯРНОГО ЛЕЧЕНИЯ КОРОНАРНО-ПРАВОПРЕДСЕРДНОЙ И ПОДКЛЮЧИЧНО-ЛЕГОЧНО-ПРАВОПРЕДСЕРДНОЙ ФИСТУЛЫ

The article gives a detailed analysis of examination and treatment of a patient with of coronary-right atrial and subclavian pulmonary- right atrial fistula. Coronary fistula is congenital anomaly when the coronary artery flows into chambers of heart that results in blood shunting and steal syndrome. The severity assessment of the clinical symptoms was performed by using ECG, x-ray chest, ECHO-CG, angiography. The embolization of the fistula using Gianturco coils and further estimation in one month and then in two months were conducted. As a result, the patient have decreased clinical symptoms of the disease i.e. walk distance increased, breath shortness decreased, lungs pneumatization increased, heart chambers size became normal. The endovascular embolization of coronary fistulas using coils is a highly effective and safe method, leading to improvement of the clinical picture.

Редкие причины возврата стенокардии после маммарно-коронарного шунтирования: синдром обкрадывания боковых ветвей внутренней грудной артерии, коронарно-подключичный steal-синдром, синдром грудного выхода

Максимальное использование артериальных кондуитов, исключение технических погрешностей при наложении анастомозов, наличие хорошего дистального русла шунтируемых артерий, адекватная медикаментозная терапия в послеоперационном периоде позволяют достичь хороших отдаленных результатов при аортокоронарном шунтировании. Однако ввиду агрессивного течения атеросклероза через определенное количество лет после операции у некоторых больных отмечается возврат стенокардии. Это, как правило, обусловлено прогрессированием атеросклероза, в который вовлекаются и кондуиты, и коронарные артерии (шунтированные и нешунтированные). Среди причин возврата стенокардии на первом месте по частоте – дисфункция шунтов (57–73%), затем прогрессирование атеросклероза в нативных или шунтированных коронарных артериях (12–23%) и исходная неполная реваскуляризация миокарда (5–8%). Повторные приступы стенокардии у больных после операции коронарного шунтирования, при которой использовалась внутренняя грудная артерия (ВГА), согласно данным шунтографии, обусловлены большей частью не поражением артериального кондуита, а прогрессированием атеросклероза в коронарных артериях дистальнее анастомоза. Кроме того, помимо основных причин дисфункции маммарно-коронарного шунта существуют такие редкие причины возврата стенокардии, как синдром обкрадывания боковых ветвей ВГА, коронарно-подключичный стил синдром, синдром грудного выхода. HTML

Subclavian steal syndrome

Literature data on the etiology, clinical picture, diagnostic variants and treatment of subclavian steal syndrome are reviewed. Different clinical variants and neurological symptoms of the syndrome are described. Multispiral computed tomography, along with ultrasound examination, is important in the diagnosis of the syndrome and its causes. The use of other methods is necessary for more accurate diagnosis and prevention of perioperative complications. The character of damage of subclavian arteries and brachiocephalic stem should be taken into account in the choice of an optimal method of surgical treatment.

Subclavian steal syndrome - surgical or endovascular treatment

Background/Aim. A phenomenon of subclavian steal is caused by occlusion or stenosis of the proximal subclavian artery with subsequent retrograde filling of the subclavian artery via the ipsilateral vertebral artery. The aim of this research was to compare surgical method [carotid-subclavian bypass grafts (CSBG)] and endovascular methods [percutaneous transluminal angioplasty (PTA) and stenting of subclavian artery] from the aspect of immediate and long-term results. Methods. Thirty patients [16 (53.33%) males], of average age between 60.1 ± 8.25 years were treated with CSBG and compared with a group of forty patients [18 (45%) males], of the average age between 57.75 ± 6.15 years treated by PTA and stenting of subclavian artery. Immediate and long-term results were determined clinically and confirmed by Doppler pressures and duplex ultrasound/angiography. All patients were followed-up after 1, 6 and 12 months post-procedure, and annually thereafter. Results. The average follow-up for both groups was 22.37 ± 11.95 months. There were 2 (6.67%) procedural complications in the CSBG group (transient ischemic attack in 2 patients) and 3 (7.5%) ones in the PTA/stent group (dissection and distal embolization in one patient and puncture site hematoma in one patient). Systolic blood pressure difference between the two brachial arteries in CSBG group was: 42.6 ± 14.5 mmHg vs 4.75 ± 12.94 mmHg (p 0.05). Conclusions. Both, the CSBG and PTA/stenting of subclavian artery are safe, efficacious and durable procedures. They have similar immediate and long-term results. PTA and stenting are the methods of choice for high grade stenosis, near total occlusions and segment occlusions of subclavian artery. CSBG is indicated in case of diffuse occlusive lesions and when the PTA and stenting do not succeed or cause complications.

頸部回旋により鎖骨下動脈盗血症候群を呈した高度鎖骨下動脈狭窄症の1例

頸部回旋により鎖骨下動脈盗血症候群を呈した高度鎖骨下動脈狭窄症の1例

鎖骨下動脈高度狭窄における同側椎骨動脈の超音波ドプラ波形に関する12症例報告

Introduction: Proximal stenosis of the subclavian artery (SCA) shows progression to subclavian steal syndrome (SSS)/phenomenon (SSP), characterized by retrograde flow in the ipsilateral vertebral artery (VA). Here we describe the clinical manifestations and ultrasound findings of ipsilateral VA in patients with high-grade stenosis of the SCA, and the role of VA ultrasound in percutaneous transluminal angioplasty (PTA) stenting of the SCA. Patients: Twelve patients (male: 10, female: 2; age: 17–86 yr) were selected from among inpatients with SCA stenosis treated in our department between 2009 and 2015. Results: The affected vessel was the left in 8 cases and the right in 4. The causes of stenosis were atherosclerosis in 10 cases, congenital in 1, and arteritis in 1. The symptoms were dizziness, faintness, syncope, diplopia, dysarthria, rest pain, coldness and arm claudication on effort. The cases were divided into SSS (n=7), SSP (n=2), and SCA stenosis only (n=3). The Doppler flow patterns were classified as normal antegrade (n=3), bunny waveform (n=0), alternating (n=6), reverse (n=2), and not detected (n=1). Ten of the patients underwent PTA stenting and 2 conservative therapy. Conclusions: Alternating and reverse flow patterns in the VA might lead to the surgical indication for PTA-stenting of SCA.

Value of Doppler Ultrasound in the Diagnosis of Dialysis Fistula - Related Vascular Complications

The aim of this study was to assess the value of doppler ultrasound in the diagnosis of vascular complications of arteriovenous (AV) fistulae in dialysis patients. 53 patients were referred during 6-month period to the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin for the ultrasound examination of the AV dialysis fistulae. There were distinguished two types of anastomoses within the group of examined patients. 38 subjects presented with end-to-side fistulae, whereas the remaining patients had side-to-side anastomoses. All dialysis fistulae were localized in the distal part of the forearm. Each examination was performed using LOGIQ 7, GE ultrasound scanner with 6-12 MHz linear probe. 12 cases of vascular complications were diagnosed among the study group including: 3 cephalic vein thromboses, 2 cephalic vein stenoses, 2 radial artery stenoses and 5 cases of the steal syndrome. All the patients diagnosed with either venous or arterial stenosis based on ultrasound examination were further qualified for PTA procedures. Doppler ultrasound examination is the method of choice in the monitoring and diagnosing vascular complications of dialysis fistulas.

Prosthetic Hemodialysis Access-induced Distal Hand Ischemia and its Contributors in Diabetics.

Avoidance of hand ischemia in the construction of prosthetic access for hemodialysis in diabetics that have no suitable vein for arteriovenous fistula is appreciated. Taper type may be an appropriately matched conduit to prevent its occurrence. This is a prospective controlled trial of 38 selected diabetics requiring hemodialysis, who were referred to our clinic during a period of 6 months. The aim of the study was to evaluate the efficacy of tapered grafts in preventing distal hand hypoperfusion and determining its most likely contributors. In 18 intervening cases, taper 4 mm × 7 mm and in twenty cases (control group), standard 6 mm polytetrafluoroethylene as straight Brachial-Axillary access was used. Graft flow rates, artery and vein diameters, and mean arterial pressure were included for evaluation. Within the control group, 11 patients (55%) (7 cases Grade 1, 3 Grade 2, 1 Grade 3) and in intervening group, 2 cases (11%) (Grade 1, Grade 3) developed Steal syndrome. There was no significant difference in the mean flow rates (P = 0.82). Increased risk of distal hypoperfusion was observed in the control group when flow rates were more than 1000 ml/min. Arterial diameters (P = 0.011) and mean arterial pressure (P = 0.05) were found to be important contributing factors. Taper grafts causes reduced incidence of distal hand hypoperfusion. When artery diameter was <6 mm and mean arterial pressure lower than 100 mmHg and the index (brachial artery diameter × mean arterial pressure) was under 500, distal hand ischemia occurred in standard and tapper type. We therefore recommend selective usage of taper grafts in diabetics with diminished distal hand pulses, considering the contributing factors when fistula first is not feasible.

Successful Percutaneous Intervention for Chronic Total Occlusion of Left Subclavian Artery

Introduction: Subclavian artery stenosis is most commonly caused by atherosclerotic disease. Surgical treatment is associated with high morbidity and mortality. Intervention is generally reserved for the management of symptomatic patients who present with upper limb ischemia, Vertebrobasilar symptoms and subclavian steal syndrome. Endovascular stenting is preferred over surgery because of high success rate, less invasive and minimal complications. Case report: Here we report a case of 56-year-old female patient with history of hypertension and diabetes presented with dizziness, vertigo and left arm claudication with use of her left upper extremity since last six months. She was diagnosed as a case of subclavian steal syndrome. Treatment: Patient underwent successful Percutaneous Transluminal Angioplasty (PTA) of the left subclavian artery with marked improvement of symptoms at follow-up. Patient was monitored with Duplex ultrasound of left subclavian artery, measurement of BP and examination of pulse at each visit. Conclusion: PTA is an effective and safe with high success rate, less invasive and minimal complications when compared to surgery for the treatment of symptomatic subclavian artery stenosis. However, regular clinical and duplex ultrasound assessment of subclavian artery is necessary after angioplasty for monitoring restenosis.

Extrathoracic Surgical Treatment of Subclavian Steal Syndrome

Twelve patients with” subclavian steal syndrome” were studied in 36 months period from June 2013 to June 2016. Their age ranged between 21-55 years with a mean age of 32 years. Female sex represented (7/12, 58.33%). All cases were subjected to complete history taking and clinical examination. They presented with drowsiness and, or fainting after left upper limb exercise. This was associated with manifestations of chronic left upper limb ischemia. Investigations were done for all cases including laboratory investigations, Duplex US, Angiography and CT Angiography. Surgical treatment was done for all cases (7 cases were treated by transcervical subclavian -subclavian bypass graft, 4 cases were treated by left common carotid to left subclavian artery bypass graft and one case by right subclavian to left axillary artery bypass graft). Ringed Gortex graft 8mm was used in all cases. The results of all surgical operations were successful and the symptoms of the brain and left upper limb ischemia disappeared. The graft in one case was occluded after 2½ years due to intimal hyperplasia (the case of right subclavian to left axillary artery bypass graft). Clearance of the graft was done by using Fogarty catheter. All grafts were functioning well and the results were excellent.

Long Term Outcomes of Arteriovenous Grafts for Hemodialysis in Lower Extremities.

Purpose:The lower extremity has received its fair share of attention as a vascular access site in patients who have exhausted their upper arm vessels. However, experiences with lower extremity arteriovenous grafts (AVGs) have so far been disappointing because of high infection rates and severe limb ischemia. We report our experience with hemodialysis access from the lower extremity.Materials and Methods:A retrospective review of 60 lower extremity AVGs created between January 2003 and December 2011 was performed. Age, sex, etiology of end-stage renal disease and complications were tabulated. Primary and secondary patency rates were determined.Results:The average age of the study population was 56 years and 38 patients were female. Renal failure was associated with hypertension in 40 (66.7%) patients, diabetes in 28 (46.7%) patients and cardiovascular disease in 9 (15.0%) patients. The follow-up period was 8–108 months. Fifty-four patients had bilateral central vein stenosis. Seven (11.7%) patients had primary failure of their AVG. There was no operation-related death. Primary and secondary patency rates were: 66% and 90% at 1 year, 40% and 90% at 2 years, 27% and 87% at 3 years, and 18% and 87% at 5 years, respectively. There were 105 postoperative complications that developed in 67 patients. Postoperative complications were: thrombosis (30), proximal vein stenosis (56), infection (9), bleeding with hematoma (1), perigraft seroma (3), steal syndrome (2), and pseudoaneurysm (4).Conclusion:A lower extremity AVG seems to be a viable option in patients with unusable upper extremity veins.

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

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