Upper Limb Ischemia After Vascular Access Surgery: Differential Diagnosis and Management

Miles, Anne Marie V.

doi:10.1046/j.1525-139x.2000.00082.x

Cited by 70 publications

(57 citation statements)

References 17 publications

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“…[15][16][17] Cases occurring immediately after fistula creation were thought to be due to a transient reduction in blood flow that caused ischemia of the vasa nervorum, but was not prolonged enough to cause tissue loss. 7,15,[17][18][19] It is most commonly associated with diabetes, atherosclerotic vascular disease, and upper arm fistulae. Immediate revascularization or ligation of the fistula is required for this acute presentation, but may not prevent permanent nerve damage.…”

Section: Neuropathies In the Differential Diagnosismentioning

confidence: 99%

“…The indications for revascularization are: 1) any proximal inflow disease with poor fistula flow 2) rest pain, muscle weakness, or necrosis in the hand 5,7,8,18,19 3) ischemic monomelic neuropathy 7,18,19 Treatment of disease proximal or distal to the fistula Proximal artery disease can be treated by percutaneous methods, as in our case, or by surgical revascularization. Percutaneous methods for proximal disease offer less morbidity, and as many patients with ischemic steal syndrome have co-existing atherosclerotic vascular disease, probably less mortality than surgery.…”

Section: Indications For Revascularizationmentioning

confidence: 99%

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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: Neuropathies In the Differential Diagnosismentioning

confidence: 99%

Section: Indications For Revascularizationmentioning

confidence: 99%

Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis

2009

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“…Its manifestations include cold sensation and pallor of the limb, pain while working or during dialysis, sensitivity loss, cramps and pain while resting, the development of ulcers, necrosis to tissue loss 19,23 . In certain cases, the problems are not caused by the steal syndrome but rather by ischemic monomelic neuropathy 35,36 . It is a question how to examine a patient with a sclerotic arterial bed and diabetes prior to the autogenous fi stula performance in order to correctly indicate elbow fi stula and how to prevent the development of a hyperfunctional fi stula with the steal syndrome.…”

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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“…Ischemic complications from AV access occur in 1-9% of patients. 1 Symptoms of steal can be mild, such as self-limited dialysis induced pain, coldness and numbness, or severe, including severe pain, sensory and motor loss. 2 If vascular compromise is sufficient, gangrene can ensue.…”

Section: Commentarymentioning

confidence: 99%

Nerves of steal

Thompson

Ajam

Stien

et al. 2008

Journal of Hospital Medicine

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A 60 year-old woman with advanced kidney disease presented with one month of progressively worsening, sharp burning pain and decreased sensation in her left hand. Cold air exacerbated the pain. She noted decreasing ability to utilize her left fingers, a weakened grip and that the muscles in her hand looked smaller.Localized sensory and motor symptoms in a discrete region of a single limb suggest neuropathy. The lack of symptoms in the face or ipsilateral lower extremity would dissuade a clinician from considering central etiologies; the presence of neuropathic pain is uncommon for cortical lesions. The involvement of motor and sensory nerves indicates peripheral nerve involvement.The general approach to patients with peripheral neuropathy begins with identifying the neuropathy as a mononeuropathy (involving a single nerve), a polyneuropathy (symmetric involvement of multiple nerves) or a mononeuropathy multiplex (asymmetric involvement of multiple nerves). The patient, in this case, described subacute neuropathic pain, sensory loss, and weakness in her left hand in a distribution consistent with mononeuropathy or mononeuropathy multiplex.This patient could have carpal tunnel syndrome given its prevalence in patients with advanced renal disease. The differential diagnosis is broad, however, and includes ulnar mononeuropathy, nerve ischemia due to vasculitis or vasculopathy, lower cervical radiculopathy (though the patient does not describe neck or radicular pain), lower brachial plexopathy, and complex regional pain syndrome.The patient was diagnosed with advanced kidney disease one year ago when biopsy revealed focal segmental glomerulosclerosis secondary to lithium. Since her diagnosis, two grafts were placed in the left upper arm in anticipation of dialysis: the first, placed seven months prior to this admission, failed to mature; the second, placed one month prior to this admission, was complicated by bleeding at the fistula site and was not yet mature. Prior to this admission she had not required hemodialysis. Her past history included hypertension, dyslipidemia, hypothyroidism, secondary hyperparathyroidism, a remote history of cervical cancer (stage unknown, recent PAP smear negative), microcytosis and schizoaffective disorder. Her medications were furosemide, amlodipine, lisinopril, atenolol, atorThe approach to clinical conundrums by an expert clinician is revealed through presentation of an actual patient's case in an approach typical of morning report. Similar to patient care, sequential pieces of information are provided to the clinician who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. 342

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Upper Limb Ischemia After Vascular Access Surgery: Differential Diagnosis and Management

Cited by 70 publications

References 17 publications

Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis

Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis

Autogenous Arteriovenous Elbow Fistula for Haemodialysis and Upper Extremity Ischemia

Nerves of steal

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