'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.     

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。     

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.     

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.     

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.     

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.     

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.     

Complications of arteriovenous fistula in dialysis patients

Repeated access to the circulation is essential to perform adequate maintenance hemodialysis (HD). Dysfunction of fistulae is the most common reason for a second intervention and recurrent hospitalization. The aim of this study was to evaluate the complications of HD fistulas seeking to evaluate the impact of age, site of arteriovenous fistula (AVF) (proximal or distal), side (left or right), and history of previous vascular access. We evaluated the clinical complications in 273 patients from the beginning of the use of the current access using the history and physical examination obtained at every dialysis session. We performed further investigations including doppler ultrasound or spiral computed tomography to confirm the clinical diagnosis. Of our patients, 40% had diabetes mellitus as the cause of end-stage renal disease. Almost half (49%) the patients dialyzed through an AVF and 13% with a catheter. One hundred eighty-four cases (67.6%) experienced complications. Of 145 cases that had elbow AVFs, 103 cases (71%) had complications; of 128 cases with wrist AVFs, 80 cases (62.5%) had complications. There were 115 (62.5%) complicated cases among 185 patients with left AVFs, and 69 (78%) among 88 patients with right AVFs. The rate of AVF complications increased with age. The 1-year survival rate was 94%. We did not observe any significant difference between AVF complications in patients with diabetes mellitus or hypertension as the underlying cause of renal failure. Mean cholesterol plasma level did not differ significantly between the patients with and without AVF complications. Mean hematocrit levels were not significantly different between the two groups. However, mean EPO weekly dose was significantly higher among the group of patients with AVF complications. We did find that rate of complications increased with age (P<.05). Our results showed that the frequency of complications was higher among patients with elbow and right-side AVFs, and also among patients with a history of a previous failed shunt but no significant relationship was observed between these variables (P>.05).     

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.     

Percutaneous placement of a constrained stent for the treatment of dialysis associated arteriovenous graft steal syndrome

Though rare, dialysis associated steal syndrome (DASS) can cause debilitating symptoms. Surgical revision of the dialysis access is typically required. We describe a percutaneous technique to alleviate steal syndrome utilizing a constrained stent within an arteriovenous graft. A brief review of the incidence, pathophysiology, and standard treatment of DASS is also provided.     

Proximal radial artery as inflow site for native arteriovenous fistula

BACKGROUND: Most vascular surgeons favor an initial radial-cephalic anastomosis at the wrist for dialysis access when possible. As populations age and more chronically ill patients are offered dialysis, this native arteriovenous fistula (NAVF) is less frequently available. A brachial-cephalic anastomosis is generally considered to be the second choice for NAVF site. We report our experience in a series of patients where the proximal radial artery (PRA) serves as the primary inflow vessel. STUDY DESIGN: We reviewed 139 consecutive dialysis access operations performed by the senior author. One hundred fourteen had an NAVF constructed. Seventy-three of these procedures in 71 patients involved the PRA as arterial inflow and are the subject of this report. RESULTS: Mean age was 57 years. Thirty-six of the 71 were men. Seventy-one percent of the patients were diabetic and more than half had previous access surgery. Twenty-nine patients underwent preoperative ultrasonographic evaluation for feasibility and planning of the NAVF fistula. The 1-month patency rate for patients undergoing PRA fistula was 98%. Cumulative patency was 80% during the followup period of up to 42 months. No infectious or ischemic complications were noted during the study period. CONCLUSIONS: We find the anterior position and mobility of the PRA offers a simple and tension-free anastomosis to the median antebrachial vein or one of its tributaries. This anastomotic site frequently allows dialysis in both the forearm and upper arm. The PRA allows for adequate arterial inflow while avoiding the risk of steal syndrome found with brachial artery fistulas. More extensive procedures or use of prosthetic grafts can be avoided.     

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.     

Questionable value of adjuvant arteriovenous fistula in pedal bypass at high risk for early failure

Results of an adjuvant arteriovenous fistula (AVF) in pedal bypass surgery in the presence of poor status of the recipient artery, severely impaired intraoperative runoff, or revision for early failure and flow restitution were analyzed in a retrospective study. From January 1998 to December 2006, 24 adjuvant AVFs were constructed in autologous vein or composite pedal bypasses with low intraoperative bypass flow, poor status of the pedal artery, or during successful early bypass revision to prevent graft failure. All infrainguinal bypass operations were registered in a computerized database and prospectively followed. Pedal bypasses with adjunctive AVF were reviewed for fistula function, graft patency, limb salvage, and patient survival. Primary and secondary bypass patency rates at 1 year were 59% and 77%, respectively, with an AVF patency of 36%. Four legs were amputated despite a patent bypass with patent AVF on three occasions. The corresponding limb salvage rate was 65% at 1 year. Patient survival was 50% at 3 years. Adjuvant AVF constructed in grafts considered at high risk for early failure in pedal vein graft or composite bypass does not seem to prevent future graft failure. In patent bypasses the fistula has a significant tendency for spontaneous occlusion. It may be considered in the use of prosthetic composite pedal grafts in selected cases.     

Treatment of steal syndrome in a distal radiocephalic arteriovenous fistula using intravascular coil embolization

Steal syndrome is a well-described complication of arteriovenous fistulas used for hemodialysis access. Although distal revascularization with interval ligation appears to offer the greatest likelihood of symptom relief and vascular access salvage, not all fistulas are amenable to this procedure, particularly distal radiocephalic arteriovenous fistulas. In this report, we describe the treatment of steal syndrome in a patient with a distal radiocephalic arteriovenous fistula using a percutaneous approach and endovascular coils. After coil embolization of the distal radial artery and multiple collateral vessels, steal was no longer visualized using angiography, and the patient's symptoms resolved.     

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.