Radiocephalic Fistula Complicated by Distal Ischemia: Treatment by Ulnar Artery Dilatation

Abstract

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. However, its frequency is increasing with the rise in numbers of elderly and diabetic patients. This complication, which is more common for proximal than for distal accesses, can be very severe and may cause loss of hand function, damage to fingers, and even amputation of fingers or the hand. Its treatment is difficult and often leads to access loss. We report here a case of severe hand ischemia related to a radiocephalic fistula successfully treated by ulnar artery dilatation.

Comparative Doppler flow measurements of the ulnar artery and of the postanastomotic radial artery in radiocephalic arteriovenous fistulas to detect steal syndromes

“…Called DASS (dialysis associated steal syndrome) (2, 5), DHIS (distal hypoperfusion ischemic syndrome) (4), HISS (hand ischemia steal syndrome) (8), DAIIS (dialysis access induced ischemia syndrome) (7) or even HAIDI (hemodialysis access-induced distal ischemia) (9) in the Anglo-Saxon literature, blood diversion consists in fact of two distinct entities : the rath-…”

“…Decreasing the fistula flow by reducing the caliber of the draining vein of the fistula does not seem to be a good solution (5). Whenever possible, arterial dilation must be recommended (1,6,8,12,14). Surgical or endovascular procedures have been proposed, such as closing the pre-or postanastomotic radial artery (in case of hyperflow).…”

Ultrasound evaluation of dialysis access-related distal ischaemia

“…Whenever the ulnar artery would be found stenosed or occluded, endovascular treatment would be quite effective, yet keeping unmodified the high flow of the radiocephalic fistula. 37 After having excluded distal artery stenosis, flow reduction through proximal radial artery ligation (PRAL) or, with the limits of reproducibility, banding is the indicated treatment option. 36,38…”

“…Whenever the ulnar artery would be found stenosed or occluded, endovascular treatment would be quite effective, yet keeping unmodified the high flow of the radiocephalic fistula. 37 After having excluded distal artery stenosis, flow reduction through proximal radial artery ligation (PRAL) or, with the limits of reproducibility, banding is the indicated treatment option. 36,38 In summary, by ultrasound evaluation, we could 1) confirm diagnosis of HAIDI, 2) establish the HAIDI flow category (¼ aetiology); 3) find out the existence of an arterial stenosis up-or downstream to the anastomosis in order to determine the right treatment option based on the anatomical and haemodynamic information on the angioaccess..…”