Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER): A Review of the Available Literature and Brief Overview of Alternate Therapies in Dialysis Associated Steal Syndrome

Abstract

Dialysis associated steal syndrome (DASS) is a relatively rare but debilitating complication of arteriovenous fistulas. While mild symptoms can be observed, if severe symptoms are left untreated, DASS can result in ulcerations and limb threatening ischemia. High-flow with resultant heart failure is another documented complication following dialysis access procedures. Historically, open surgical procedures have been the mainstay of therapy for both DASS as well as high-flow. These procedures included ligation, open surgical banding, distal revascularization-interval ligation, revascularization using distal inflow, and proximal invasion of arterial inflow. While effective, open surgical procedures and general anesthesia are preferably avoided in this high-risk population. Minimally invasive limited ligation endoluminal-assisted revision (MILLER) offers both a precise as well as a minimally invasive approach to treating both dialysis associated steal syndrome as well as high-flow with resultant heart failure. MILLER is not ideal for all DASS patients, particularly those with low-flow fistulas. We aim to briefly describe the open surgical therapies as well as review both the technical aspects of the MILLER procedure and the available literature.

Pledgeted plication: A novel technique to treat dialysis access-related steal syndrome

“… 6 Newer interventions such as the minimally invasive limited ligation endoluminal-assisted revision (MILLER) technique use angiography with balloon angioplasty to determine the optimal degree of narrowing and as a guide for banding. 10 , 11 Simple plication, a technique that may be more effective in autologous fistulas over synthetic grafts, entails narrowing the vein proximal to the anastomosis with uninterrupted polypropylene suture. 5 As with banding, this technique increases resistance within the vein and improves flow through the artery.…”

Venous outflow banding for maturation of a percutaneous arteriovenous fistula

“…Alternative, more controlled, banding techniques using balloon angioplasty catheters have been described and could be used in the future. 12 Although accessory vein embolization and/or ligation are options for AVFs that fail to mature, banding provides an alternative to preserve veins that could be conduits for future access.…”

A modified banding technique: experience of a center

“…Modified banding techniques such as the MILLER procedure have proved effective in treating these cases 14 , 15 , 16 but are not widely available. They are also more invasive than our presently reported technique and more dependent on operative skills and experience.…”