Hand Ischemia Associated With Dialysis Vascular Access: An Individualized Access Flow‐based Approach to Therapy

Abstract

With the rise in the median age of hemodialysis patients, the increasing numbers of patients with multiple risk factors for vascular disease, and the efforts being made to increase the creation of autogenous arteriovenous fistulas (AVFs), dialysis access-related steal syndrome (DASS) has become a growing problem. This syndrome, caused by arterial insufficiency distal to the arteriovenous access due to diversion of blood into the access, is a potentially devastating complication. It is crucial that physicians who manage hemodialysis patients and perform vascular access procedures have a comprehensive understanding of the pathophysiology, symptoms, diagnostic maneuvers, and treatment options for DASS. The goals of management must be twofold-relieve the ischemia and preserve the access. The choice of any intervention, if such is necessary, should be based upon the clinical features presented by that individual patient; the clinical condition and prognosis of the patient, stage of the disease, location of the arterial anastomosis, and the level of blood flow within the access. This review presents information that supports an individualized, physiologic approach to this condition.

Basilic vein transposition for unsuitable upper arm hemodialysis needle access segment may attenuate concurrent hand ischemia

“…A diagnosis of hand ischemia due to an HD‐access is suspected on specifics of the patient's history . Pain, coldness and altered skin sensation in the ipsilateral hand as well as diminished strength and muscle cramps are often reported . Moreover, these subjective symptoms may be provoked during HD as systemic blood pressure and peripheral perfusion pressures drop toward the end of a HD‐session .…”

“…27,28 Pain, coldness and altered skin sensation in the ipsilateral hand as well as diminished strength and muscle cramps are often reported. 29,30 Moreover, these subjective symptoms may be provoked during HD as systemic blood pressure and peripheral perfusion pressures drop toward the end of a HD-session. 15 Pain in the affected limb that occurs or aggravates during HD can be a hallmark of impending ischemia and should never be ignored.…”

Correlation of Hand Ischemic Questionnaire with Digital Brachial Index In Patient with Upper Arm Native Arteriovenous Fistula

“…DBI is considered superior to confirm the diagnosis of steal syndrome compared to other investigations. 6 In this study DBI of <0.6 was used as a cut-off to determine which patients were suggestive of steal syndrome. Based on the data obtained from the total score of the HIQ, the minimum value was 0, and the maximum value was 70, with a median value of 3.…”

“…5 Risks for steal syndrome include the use of brachial arteries as inflow, diabetes, age >60 years, smokers, female sex, and history of repeated ipsilateral access. 6 Although there was no gold-standard examination, there were various non-invasive predictors that can assess the degree of stealing, one of which is the digital brachial index (DBI) value. DBI of <0.6 is considered significant to assess the risk of stealing in patients.…”

Clinical Outcomes after Arteriovenous Fistula Creation in Chronic Kidney Disease

“…As commonly seen in patients with severe CKD, the patients in our study had a high baseline rate of cardiac disease, indicating that this population may be particularly susceptible to any adverse cardiovascular impact of AVF surgery. Other important complications to consider with AVF surgery include the risk of hand ischaemia caused by steal syndrome [25,26,27] and the risk of immediate peri-operative complications.…”