Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access

PURPOSE: The treatment of hemodialysis access-induced ischemic steal syndrome is challenging. Despite promising early results with the distal revascularization-interval ligation (DRIL) procedure, the operation has not been widely adopted because of concerns about its complexity and long-term efficacy. The purpose of this report was to determine the efficacy and durability of the DRIL procedure in relieving hand ischemia and in maintaining access patency in the setting of hemodialysis access-induced ischemia. METHODS: A retrospective review was performed of all patients who underwent the DRIL procedure for access-induced ischemia. Demographic information was compiled, as were data regarding access and bypass patency, limb salvage, and patient survival. Arteriovenous access and brachial artery bypass patency rates were determined with life-table methods. RESULTS: Between 1995 and 2001, we performed 55 DRIL procedures in 52 patients (35 women and 17 men; mean age, 60.8 years; range, 30 to 86 years). The indications for surgery were ischemic pain in 27 patients, tissue loss in 20 patients, loss of neurologic function in four patients, and pain on hemodialysis in one patient. Most patients (92%) had diabetes. The mean interval from access placement to DRIL was 7.4 months (range, 1 to 84 months). The mean follow-up interval was 16 months (range, 1 to 67 months). The brachial artery bypass primary patency rate was 80% at 4 years, and the arteriovenous access primary patency rate was 83% at 1 year. Forty-seven of 52 patients (90%) had substantial or complete relief of ischemic hand symptoms, and 15 of 20 patients with digital ischemic lesions have healed completely. CONCLUSION: DRIL is a durable and effective procedure that reliably accomplishes the twin goals in the treatment of angioaccess-induced ischemia: persistent relief of hand ischemia and continued access patency.     

结扎桡动脉远心端治疗透析通路相关缺血综合征

目的总结结扎桡动脉远心端治疗透析通路相关缺血综合征的方法及经验。方法选择2011年6月至2013年12月北京大学第三医院海淀院区肾内科以头静脉-桡动脉端侧吻合动静脉内瘘为透析通路,且临床表现为内瘘侧肢体缺血者16例,行彩色多普勒超声检查显示吻合口桡动脉近心端及远心端血流方向相反,行血管造影显示大动脉通畅,行Allen实验提示尺动脉功能良好,采用局部浸润麻醉结扎吻合口桡动脉远心端治疗肢体远端自体动静脉内瘘相关缺血综合征,术后观察缺血症状缓解情况、透析时内瘘泵控血流量、尿素清除指数、尿素下降率、内瘘通畅性等指标。结果共观察上肢远端自体动静脉内瘘相关缺血综合征16例(占同期因动静脉内瘘并发症住院患者的1.45%),其中男性8例,女性8例,平均年龄(66.2±11.2)岁,平均透析时间(66.32±85.26)个月,内瘘时间(57.75±88.41)个月,内瘘建立后出现缺血症状时间(39.62±58.31)个月;根据临床表现的缺血症状进行分级,其中13例(占71.40%)为Ⅲ级患者,3例(28.60%)为Ⅱ级,未出现Ⅳ级患者。结扎桡动脉远心端手术技术成功率100%,临床成功率93.70%(15/16)。术前及术后第7天、第6个月、第12个月入组患者透析泵控血流量分别为(258.63±25.44)ml/min、(246.61±24.24)ml/min、(260.42±20.83)ml/min、(254.87±22.44)ml/min,差异无统计学意义(P0.05);尿素清除指数分别为(1.65±0.21)、(1.59±0.24)、(1.62±0.28)、(1.58±0.39),差异无统计学意义(P0.05);尿素下降率分别为(78.43%±3.27%)、(74.46%±2.64%)、(76.85%±3.84%)、(74.21%±3.32%),差异无统计学意义(P0.05),术后平均随访(19.30±13.15)个月,通畅率100%。未出现严重并发症。结论结扎桡动脉远心端治疗上肢远端自体动静脉内瘘相关缺血综合征简便、安全、有效,保留宝贵血管资源,同时延长内瘘使用寿命,可作为处理缺血综合征的一种方法。     

Hemodialysis-related steal syndrome: predictive factors and response to treatment with the distal revascularization-interval ligation procedure

Hand ischemia due to steal causes major disability in affected members of the hemodialysis population. Between February 2000 and March 2007, 24 patients aged 37-77 years were identified who developed hand ischemia distal to a hemodialysis access and required a distal revascularization-interval ligation (DRIL) procedure. Of the 24 patients, 22 (92%) were diabetic, 14 (58%) were women, 7 (29%) had prosthetic grafts, and 17 (71%) had fistulas, all originating from the brachial artery. Duration between the initial dialysis access and the DRIL procedures ranged 12 hours to 10 months. Conduits used were saphenous vein in 13 (54%) cases, cephalic vein in 3 (12%) cases, basilic vein in 5 (21%) cases, and prosthetic grafts in 3 (12%) cases. There were no operative deaths. Improved blood flow and relief of symptoms were observed in 23 (96%) patients. The procedure failed early in one patient who had thrombosis of a prosthetic graft. Two patients required digital amputations. At a median follow-up of 50 months, 14 (58%) patients died using the access requiring the DRIL, 2 (8%) did not require dialysis, 3 (12%) were using a new access, and 5 (21%) were still using the access that had required the DRIL. In late follow-up, only one DRIL bypass required revision and the remainder were patent. One patient developed an ischemic hand 5 years after his DRIL procedure despite a patent bypass. The development of ischemic steal requiring performance of a DRIL procedure is most likely to occur in diabetic patients with dialysis access originating from the brachial artery. The procedure is effective in ameliorating symptoms while preserving the vascular access. The high long-term mortality rate observed in this series underscores the fact that patients requiring a DRIL procedure represent a subset of dialysis patients with advanced diabetic vascular disease and a limited life expectancy. Despite the effectiveness of the DRIL procedure, efforts should be concentrated on prevention of ischemic steal in order to lessen the morbidity and expense of this condition in the dialysis population.     

Management of steal syndrome resulting from dialysis access

Ischemic steal secondary to a hemodialysis arteriovenous (AV) access occurs in approximately 10% of cases. The pathophysiological basis of this condition is a marked decrease or reversal of flow in the arterial segment distal to the AV fistula or AV graft, induced by the low resistance of the fistula outflow. Clinically it can manifest with either mild symptoms (coolness, paresthesia, and absence of distal pulses), or severe symptoms (rest pain, severe paresthesia, paralysis, cyanosis, and gangrene) immediately after construction of the AV access or later after its inception. Diagnosis is based on clinical manifestations, aided by the vascular laboratory and angiography. Mild cases can be observed closely, most of them will reverse in a few weeks. In order to prevent permanent sequela, severe cases require immediate intervention. Several surgical treatments have been used: access ligation, banding, elongation, distal arterial ligation, and distal revascularization-interval ligation. Best results, with maintenance of access function and reversal of symptoms, have been obtained with the distal revascularization-interval ligation procedure.     

Modified distal revascularization with interval ligation procedure for steal syndrome after arteriovenous fistula creation for hemodialysis access

Patients diagnosed with steal syndrome after hemodialysis access surgery have a few options for symptom relief while maintaining vascular access. These include fistula lengthening, banding, distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI) or proximalization of the arterial inflow (PAI). Two cases are described in which a modified DRIL procedure without interval ligation was used to relieve steal syndrome, leaving the arterial supply of an ischemic hand not entirely dependent upon a bypass. Furthermore, a review of the literature is presented in order to elucidate this relatively new treatment option as a viable means to improve hand perfusion while maintaining a functional fistula.     

Distal revascularization and interval ligation (DRIL) procedure for the treatment of ischemic steal syndrome after arm arteriovenous fistula

The objective of this study was to investigate the efficacy of the distal-revascularization-interval ligation (DRIL) technique in alleviating symptoms of ischemic steal syndrome and in preserving hemodialysis access. A retrospective chart review was conducted of all patients receiving the DRIL procedure in a 3-year period. There were 38 DRIL bypass grafts identified in 35 patients, with 36 DRILs with follow-up adequate for analysis. Comparison of preoperative and postoperative digital pulse volume recording (PVR) data was made using the t-test. The majority of patients presented with multiple ischemic symptoms, most commonly coolness, pain, and paresthesias. Six patients presented with frank digital necrosis. The mean interval to DRIL was 4.9 months following fistula construction (range 0.1-24). In 66.7% of patients for whom complete follow-up data were available (24/36), all ischemic symptoms were alleviated by DRIL. Of the remaining 12 patients, 11 experienced partial symptom relief. One patient required digital amputation following DRIL. A comparison of pre- and post-DRIL PVRs illustrated a significant increase in these values following DRIL (P < 0.05). DRIL effectively eliminates ischemic symptoms in the majority of patients and produces a significant increase in flow to the ischemic limb. The data support the usage of DRIL as the procedure of choice in the correction of ischemic steal following arm arteriovenous fistula.     

Strategies for predicting and treating access induced ischemic steal syndrome.

Access induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. A number of clinical risk factors have been identified to select patients at risk. Intraoperative measurement of the digital-brachial index may further distinguish at-risk patients when the DBI is <0.45. Once clinically significant steal has developed, surgical strategies to treat this problem should ideally reverse the ischemia while maintaining uninterrupted access for hemodialysis. To date, the distal revascularization-interval ligation or DRIL procedure has been the most consistently successful tactic in achieving these dual objectives. A number of alternative strategies have recently been proposed and will be discussed.     

Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access

The recently published guidelines of the National Kidney Foundation-Dialysis Outcome Quality Initiative have focused on improving patient outcomes and survival by providing recommendations for optimal clinical practice. These guidelines firmly endorse the establishment of autogenous hemodialysis access and recommend a 40% to 50% prevalence of autogenous fistulas among all hemodialysis patients. As surgeons strive to meet these guidelines it will be necessary to extend autogenous reconstruction to older individuals, diabetics, and patients with suitable vein only in the upper arm. These individuals are at increased risk for the development of the ischemic steal syndrome. It is paramount that surgeons who perform vascular access procedures have a firm understanding of the symptoms, diagnostic maneuvers, and treatment options for the ischemic steal syndrome after hemodialysis access procedures.     

Strategies for management of ischemic steal syndrome

Constructing vascular access for hemodialysis causes changes in blood flow to the extremity, which can lead to distal ischemia. Ischemic steal syndrome is manifested by pain; weakness; pallor; and, in severe cases, ulceration and tissue loss. Severe ischemia, requiring reintervention, has an incidence of 4%, although some degree of ischemia causing pain or parasthesias occurs in 10% to 20% of patients following access construction. 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. Predicting steal remains difficult, although certain patient characteristics and preoperative techniques can help identify those patients in whom arteriovenous fistulas have an increased risk of causing steal. Patients with diabetes, multiple access procedures, and constructions based on proximal arteries are more prone to ischemia. Ultrasonography and digital-brachial indices measured by photoplethysmography or Doppler techniques have been used to predict fistulas that are more likely to cause ischemia, but these fall short of reliability. Operative techniques for correcting steal include arteriovenous fistula ligation, percutaneous transluminal angioplasty, banding or restrictive procedures, and distal revascularization interval ligation or modifications of this technique. Operative intervention for ischemic steal syndrome successfully resolves ischemia in 80% to 95% of patients. Some patients can have persistent pain despite healing of ulceration.     

维持性血液透析患者透析通路相关缺血综合征发病率及相关因素

目的 调查维持性血液透析患者透析通路相关缺血综合征及窃血现象发病率,对缺血综合征发生的危险因素进行分析.方法 采用横断面研究,选取2012年1至3月在北京市海淀医院以头静脉-桡动脉端侧吻合自体动静脉内瘘为通路行维持性血液透析者71例,询问并检查患者是否存在内瘘侧肢端发凉、发绀等缺血症状;应用彩色多普勒超声观察动静脉内瘘吻合口桡动脉近心端、远心端是否存在反向血流,测量内瘘吻合口、桡动脉、肱动脉内径及血流量;记录入组患者性别、高血压、糖尿病、吸烟和动脉硬化等,对上述指标进行量化后行logistic回归分析.结果 透析通路相关缺血综合征发病率为19.7％（14/71）.彩色多普勒超声显示,桡动脉远端血流方向及频谱方向均为反向者42例（59.2％）.多元回归分析显示,内瘘口径大小、肱动脉血流量、女性、糖尿病、动脉硬化不是缺血综合征的危险因素（均P＞0.05）.结论 动静脉内瘘后,缺血综合征发生率不低,目前尚不能通过控制内瘘口径大小等方法预防其发生.     

Primary arteriovenous fistula inflow proximalization for patients at high risk for dialysis access-associated ischemic steal syndrome

Establishing a functional vascular access while minimizing the risk of dialysis access-associated ischemic steal syndrome (DASS) may present a challenging problem in patients with severe peripheral vascular disease where even a low-flow arteriovenous fistula (AVF) may lead to severe symptoms and physical findings of DASS. Proximalization of arterial inflow for an existing vascular access is established as an effective treatment for DASS. We hypothesized that a primary proximal arterial inflow procedure for vascular access in patients judged to be at high risk for DASS would result in a successful hemodialysis access and mitigate the risk of steal syndrome. We report four such patients considered to be at significant risk for DASS after construction of a new vascular access. An axillary artery AVF inflow anastomosis was constructed in each patient. The access outflow configuration varied with the available venous outflow conduit identified during the preoperative ultrasound evaluation. In all four patients in this report, a functional autogenous dialysis access was established without DASS.     

Subclavian steal syndrome from high-output brachiocephalic arteriovenous fistula: a previously undescribed complication of dialysis access

A 28-year-old dialysis-dependent man presented with episodic vertebrobasilar insufficiency. Noninvasive studies demonstrated an estimated 5.8 L/min flow through the arteriovenous fistula in his left arm and reversal of flow in the left vertebral artery. Surgical reduction of fistula flow resulted in the elimination of symptoms and the return of antegrade flow in the left vertebral artery. intraoperative invasive monitoring corroborated the pressure gradient responsible for his subclavian steal syndrome.     

Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies

Distal hypoperfusion ischemic syndrome (DHIS), commonly referred to as hand ischemia or 'steal' after dialysis access placement, occurs in 5-10% of cases when the brachial artery is used, or 10 times that of wrist arteriovenous fistulas (AVFs) using the radial artery. It is typically seen in elderly women with diabetes, and may carry severe morbidity including tissue or limb loss if not recognized and treated. Three distinct etiologies include (1) blood flow restriction to the hand from arterial occlusive disease either proximal or distal to the AV access anastomosis, (2) excess blood flow through the AV fistula conduit (true steal), and (3) lack of vascular (arterial) adaptation or collateral flow reserve (ie atherosclerosis) to the increased flow demand from the AV conduit. These three causes of steal may occur alone or in concert. The diagnosis of steal is based on an accurate history and physical examination and confirmed with tests including an arteriogram, duplex Doppler ultrasound (DDU) evaluation with finger pressures and waveform analysis. Treatment of steal includes observation of developing symptoms in mild cases. Balloon angioplasty is the appropriate intervention for an arterial stenosis. At least three distinct surgical corrective procedures exist to counteract the pathophysiology of steal. The ultimate treatment strategy depends on severity of symptoms, the extent of patient co-morbidity, and the local dialysis access technical team support and skills available.