Steal Syndrome Complicating Hemodialysis Access Procedures: Can It Be Predicted?

Goff, Charles D.; Sato, Dean T.; Błoch, P; DeMasi, Richard J.; Gregory, Roger T.; Gayle, Robert G.; Parent, F. Noel; Meier, George H.; Wheeler, Jock R.

doi:10.1007/s100169910025

Cited by 121 publications

(87 citation statements)

References 12 publications

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“…However, ischemic symptoms develop in only a minority of cases. A variety of noninvasive investigations such as digital BP, digital/brachial index (DBI) measurement, digital plethysmography, duplex ultrasonography, and transcutaneous oxygen saturation determination are available to assist in the evaluation of patients with symptoms that suggest arterial steal (31)(32)(33)(34)(35)(36).…”

Section: Diagnosismentioning

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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Section: Diagnosismentioning

confidence: 99%

Arteriovenous Access and Hand Pain

León

Asif

2007

Clinical Journal of the American Society of Nephrology

125

104

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“…The physiological steal is a demonstrable drop in blood pressure at the periphery and is compensated by the arterial collateral circulation and vasodilation. If these mechanisms fail, the symptomatic form occurs in 3.7-8 % of the fi stulas 14,19,25,30,34 . In the brachiocephalic and brachiobasilic fi stulas it even appears in as much as 10-25 % 19 .…”

Section: Resultsmentioning

confidence: 99%

“…There is probably no imaging method to indicate the fi stula type. There is also no demonstrable method to clearly determine, before or after the fi stula performance, that the fi stula will be hyperfunctional with steal demonstrations 34,37 . However, imaging can determine where the fi stula should not to be attempted because the arterial or venous bed does not provide a solid basis for a satisfactory result.…”

Section: Resultsmentioning

confidence: 99%

Autogenous Arteriovenous Elbow Fistula for Haemodialysis and Upper Extremity Ischemia

Bachleda¹,

Utíkal²,

Kojecký³

et al. 2007

BIOMED PAP

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Background:The autogenous brachiocefalic or brachiobasilic arteriovenous elbow fi stula is not considered to be only the secondary haemodialysis access. In patients with an unsuitable forearm vessel bundle, it is indicated as primary access and it is the method preferred to the fi stula creation using a vascular prosthesis. Its rather rare complication is the development of upper extremity ischemia.Aim: To summarise current knowledge of this fi stula type and its associated complications Methods: Review of the literature. Results:The creation and maturation of the fi stula and occurrence of the steal syndrome is infl uenced by a number of factors. The analysis and awareness of such factors will provide for creation of a suitable fi stula as well as for timely complication diagnostics and treatment.Conclusions: The autogenous elbow fi stula utilising the brachial artery and the cephalic or basilic vein in the upper extremity represents a high-quality haemodialysis access. Its potential complication is the occurrence of the steal syndrome. Its occurrence and manifestations do not constitute indications for ligation of the access. The gathered information shows that a suitable surgical procedure can help meet the basic rule for haemodialysis access -resolving the ischemia and maintaining the access.

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“…[2][3][4] Clinically significant ischemic steal syndrome can be expected in 1%-8% of patients with this type of dialysis access, and risk factors include female sex, diabetes, age older than 60 years, multiple previous AVF access sites in the same extremity and use of the brachial artery for fistula inflow. [5][6][7] Several options are available for the treatment of ischemic steal secondary to AVF dialysis access. These include ligation of the fistula, which sacrifices the access site.…”

Section: Discussionmentioning

confidence: 99%