Hand ischemia in patients with hemodialysis access grafts: angiographic diagnosis and treatment.

Valji, Karim; Hye, Robert J.; Roberts, Anne C.; Oglevie, Steven B.; Ziegler, Thomas W.; Bookstein, Joseph J.

doi:10.1148/radiology.196.3.7644631

Cited by 110 publications

(72 citation statements)

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“…22 Flow-limiting disease distal to the fistula can be treated by angioplasty, 11 or by surgical bypass that may be part of a surgical revision of the fistula. Severe hand steal from a radiocephalic fistula due to reverse flow in the more distal radial artery can be treated by percutaneous radial artery embolization 12 or ligation (distal radial artery ligation, DRAL), 18,23 providing there is antegrade flow in the ulnar artery and an adequate palmar arch.…”

Section: Indications For Revascularizationmentioning

confidence: 99%

Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis

2009

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Arteriovenous fistulae in the arm are commonly used for hemodialysis in end-stage renal disease. Although physiological steal with reverse flow in the artery distal to the fistula is common, hand ischemia or infarction are rare. The ischemic steal syndrome (hand or forearm ischemia) is usually a result of arterial disease proximal or distal to the fistula and/or poor collateral supply to the hand. The diagnosis is primarily clinical; however, markedly reduced digital pressures and pulse volume recordings support the diagnosis. Management requires imaging for focal stenoses or disease in arteries proximal and distal to the fistula from the aorta to the hand. We present a case caused by subclavian artery occlusion that was initially missed due to focusing investigation only on the fistula. We describe the percutaneous treatments and surgical revisions that attempt to restore flow to the hand without compromising the fistula.

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Section: Indications For Revascularizationmentioning

confidence: 99%

Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis

2009

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“…Using arteriography, the incidence of arterial stenosis in patients with peripheral ischemia has been reported to range from 62 to 100% (5,8 -10). In one study (8), complete arteriography from the aortic to the palmar arch was performed to assess the presence of arterial stenosis in HD patients who presented with symptoms of peripheral ischemia (n ϭ 13). It was found that 62% of the 13 patients who were referred for the evaluation of symptoms of steal syndrome demonstrated a significant (Ն50%) arterial stenosis.…”

Section: True Steal From the Forearm Arteriesmentioning

confidence: 99%

“…In one study, Valji et al (8) performed arteriography to evaluate patients with symptoms of hand ischemia. The entire arterial tree from the aortic arch to the palmar arch was evaluated.…”

Section: Percutaneous Interventionsmentioning

confidence: 99%

Arteriovenous Access and Hand Pain

León

Asif

2007

Clinical Journal of the American Society of Nephrology

125

104

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An ischemic hand in a hemodialysis patient is a serious condition. It causes significant pain and discomfort but also can lead to tissue necrosis and the eventual loss of digits and even the entire hand. Although stealing of blood away from the high-resistance forearm arteries into the low-resistance arteriovenous access generally is assumed to be the cause, a great majority of both wrist and elbow accesses demonstrate retrograde flow without any evidence of hand pain or ischemia. Consequently, demonstration of retrograde flow alone does not predict or indicate the existence of distal ischemia. In this context, the term "arterial steal syndrome" is a misnomer to indicate the presence of peripheral ischemia. Recent studies have shown that, in many cases, arterial stenotic lesions cause distal hypoperfusion and result in hand ischemia. In other cases, distal arteriopathy as a result of generalized vascular calcification and diabetes is the culprit. Because any or a combination of the three mechanisms (retrograde flow, stenotic lesions, and distal arteriopathy) can lead to peripheral ischemia, distal hypoperfusion ischemic syndrome is a more appropriate term to denote hand ischemia. Treatment should start with a detailed history and physical examination to help rule out other (nonischemic) causes of hand pain. A complete arteriogram to evaluate the circulation of the extremity from the aortic arch to the palmar arch is essential. The choice of treatment modality and procedure to apply should be based on this evaluation. This report reviews the pathophysiology and presents current strategies to ameliorate distal hypoperfusion ischemic syndrome.

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“…Although manual compression is a near-diagnostic test for the existence of the steal syndrome, the surgeon should always obtain a preoperative angiography of the entire arm before performing DRIL [7]. Such an angiography ought to be performed pre and post manual compressing of the AVA [17]. It will provide anatomic details regarding possible proximal and peri-access arterial stenosis and will also detail patency of the distal arterial tree.…”

Section: Resultsmentioning

confidence: 99%