Dialysis access-associated steal syndrome: the intraoperative use of duplex ultrasound scan

Dialysis access-associated steal syndrome (DASS) is an uncommon but serious complication after the creation of an arteriovenous shunt for hemodialysis and is related to an excess perfusion of the fistula. Several surgical options have been described for DASS correction. To achieve an adequate distribution of the blood flow towards the fistula and the hand, intraoperative duplex ultrasound scan monitoring was used in this preliminary communication to control the surgical reduction of volume flow through the fistula. The shunt flow was not estimated with direct insonation of the shunt but calculated from the difference of the bilateral subclavian artery volume flow rates. This new technique has several advantages over a direct shunt evaluation that are discussed in this report. Three patients with DASS are described in whom the technique was successfully applied and led to a normalization of the hand perfusion and to the maintenance of a long-term patency of the fistula.     

Distalization of the anastomosis: an effective treatment for dialysis access-associated steal syndrome

Steal syndrome after arteriovenous fistula formation for dialysis access can cause ischemic pain and tissue loss. This is an indication for surgical revision, usually either banding (or ligation) or the distal revascularisation and interval ligation procedure. However, banding is inexact, and distal revascularisation and interval ligation can further compromise the arterial supply to the arm. We report three cases in which an alternative approach of moving the arteriovenous anastomosis distally was used, thereby protecting arterial inflow to the hand. In all three cases, the steal resolved and the fistula remained patent.     

Management of dialysis access-associated "steal" syndrome with DRIL procedure: challenges and clinical outcomes

Purpose: 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. Methods: 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. Results: 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. Conclusions: 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.     

'Extension technique': a modified technique for brachio-cephalic fistula to prevent dialysis access-associated steal syndrome.

OBJECTIVES: To describe a modification in brachio-cephalic fistula formation for prevention of dialysis access-associated steal syndrome (DASS). DESIGN: Short report. MATERIALS: From September 2001 to December 2003, 32 upper arm autogenous fistulae were formed using the 'extension technique' in patients at high-risk for developing DASS i.e. diabetics. METHODS: In this technique, the fistula is formed by anastomosing the median vein to the radial or ulnar artery just below the brachial bifurcation, thus preserving part of the blood supply to the hand, to prevent steal syndrome. All patients were evaluated for patency, adequacy of needling and the absence of steal symptoms. RESULTS: Only 1 patient (3.1%) developed DASS. On investigation, he was found to have the fistula formed distal to the origin of a posterior branch with the bifurcation further distally. Symptoms improved with revision of the fistula. Thrombosis of the cephalic vein (6.2%), difficulty in needling (3.1%) and deep cephalic vein in upper arm that required superficialization (15.6%) were the other complications noted. CONCLUSIONS: The 'extension technique' has been found to be a safe and effective procedure for prevention of DASS, with a good patency rate. Additional advantage of this technique is maturation of both cephalic and basilic veins.     

Management of dialysis access-associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction.

Dialysis access-associated steal syndrome (DASS) is an uncommon complication after the creation of an arteriovenous fistula and can cause irreversible ischemic damage in severe cases. Dialysis access-associated steal syndrome has been managed with the surgical reduction of the volume flow in the fistula, but this is associated with a certain incidence of access loss. Several methods are described to achieve the delicate balance between essential flow in the fistula and an adequate limb perfusion pressure. We have developed a new method with duplex ultrasound scanning to quantitate the reduction in volume flow, which will allow effective dialysis and provide adequate limb perfusion. The preoperative assessment was reproduced on the operating table with intraoperative duplex scanning. A 65-year-old woman who underwent this treatment has had resolution of her ischemic symptoms and maintains long-term patency of her dialysis access.     

Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome

Dialysis-associated steal syndrome (DASS) is defined as a clinical condition caused by arterial insufficiency distal to the dialysis access owing to diversion of blood into the fistula or graft. The incidence of symptomatic DASS requiring treatment is 1-8%. The etiology is iatrogenic and symptoms are quite debilitating. Banding of the access inflow has largely been abandoned because of the inherent problem with balancing fistula flow with distal flow complicated by a high incidence of subsequent access thrombosis. In this study, we are reporting a modification to the traditional banding procedure, which markedly improves banding outcomes. We are reporting 16 patients who underwent a new standardized minimally invasive banding procedure performed in an outpatient setting with minimal morbidity. This modified banding procedure requires a small (1-2 cm) skin incision for the placement of a ligature and utilizes a 4 or 5 mm diameter endoluminal balloon to achieve and standardize the desired reduction of inflow size. All 16 patients had immediate symptomatic and angiographic improvement after the procedure. Follow-up showed none of the patients had recurrence of symptoms or thrombosis of the access. In our experience, this procedure is an excellent treatment option because of its simplicity and should be considered as a first-line treatment for patients with DASS.     

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.     

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。     

Myocardial thievery: the coronary-subclavian steal syndrome

Coronary-subclavian steal syndrome entails the reversal of blood flow in a previously constructed internal mammary artery coronary conduit, which produces myocardial ischemia. The most frequent cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. Although coronary-subclavian steal was initially reported to be rare, the increasing documentation of this phenomenon and its potentially catastrophic consequences in recent series suggests that the incidence of the problem has been underreported and that its clinical impact has been underestimated. We review the causes and background of coronary-subclavian steal; methods of preventing, diagnosing, and treating it; and the potential influence of various treatment regimens on long-term survival and the likelihood of late adverse events in patients with coronary-subclavian steal syndrome.     

Dialysis shunt-associated steal syndrome (DASS) following brachial accesses: the value of fistula banding under blood flow control

Background  Dialysis shunt-associated steal syndrome (DASS) is a rare complication of hemodialysis access (HA) which preferably occurs in brachial fistulas. Treatment options are discussed controversially. Aim of this study was to evaluate flow-controlled fistula banding. Materials and methods  Patients treated between 2002 and 2006 were included in this prospective survey. According to a classification we established, patients were typed DASS I–III (I: short history, no dermal lesions; II: long history, skin lesions; III: long history, gangrene). Surgical therapy was HA banding including controlled reduction (about 50% of initial flow) of HA blood flow (patients type I and II). Patients with type III underwent closure of the HA. Results  In 15 patients with relevant DASS, blood-flow-controlled banding was performed. In ten patients (all type I), banding led to restitution of the hand function while preserving the HA. In five patients (all type II), banding was not successful; in two patients, closure of the HA was performed eventually. In five patients (type III), primary closure of the HA was performed. Four patients with DASS type II but only two with DASS type I had diabetes mellitus (p = 0.006). Conclusions  Banding under blood flow control resulting in an approximately 50% reduction in the initial blood flow is an adequate therapeutic option in patients with brachial HA and type I-DASS. In type II-DASS, banding does not lead to satisfying results, more complex surgical options might be more successful. Diabetes is associated with poor HA outcome in case of DASS.