Venous Side Branch Ligation as a First Step Treatment for Haemodialysis Access Induced Hand Ischaemia: Effects on Access Flow Volume and Digital Perfusion

Abstract

Ligation of non-functional venous side branches of an autogenous brachial artery AVF causing hand ischemia leads to prolonged attenuation of hand ischemia whereas access flow volumes are maintained after 1 year of follow up. Side branch ligation must be considered prior to embarking on more invasive surgery for HAIDI.

Basilic vein transposition for unsuitable upper arm hemodialysis needle access segment may attenuate concurrent hand ischemia

“…For instance, access outflow banding diminished HIQ‐scores from 153 ± 33 to 42 ± 15 whereas ischemia was largely abolished . Moreover, SBL in another population of HAIDI patients decreased HIQ‐scores from 184 ± 21 to 60 ± 15 . Conversely, HIQ‐scores in a random HD‐population not reporting hand ischemia were predictably <50 using this 0‐ to 500‐point scale…”

“…Accepted invasive therapies for HAIDI include proximalization of arterial inflow, revision using distal inflow or distal revascularisation and interval ligation but these techniques require an extensive operative dissection. However, a minimally invasive technique of ligation of patent venous access SBs was also found to attenuate symptoms of hand ischemia in two recent studies as did coil embolization in another study . A BVT procedure that is popularized for patients with an insufficient upper arm NAS may in essence be regarded as an extended version of SB ligation.…”

“…Pain in the affected limb that occurs or aggravates during HD can be a hallmark of impending ischemia and should never be ignored . The use of a HIQ allows for quantification of the five cardinal symptoms associated with hand ischemia . Interestingly, HIQ‐scores and digital brachial indices, the latter generally accepted as the only parameter objectively reflecting hand ischemia, were inversely related underscoring the potential validity of a HIQ.…”

“…Scores range from 0 (no symptoms associated with ischemia) to 500 (maximal symptoms of ischemia) . Several studies have indicated that a HIQ‐score reflects grade of ischemia and may be used to determine efficacy of remedial surgery . For instance, access outflow banding diminished HIQ‐scores from 153 ± 33 to 42 ± 15 whereas ischemia was largely abolished .…”

“…Recent studies demonstrated that patent venous side branches (SB) of a brachial artery‐based AVF also may lead to blood pressure loss and may contribute to hand ischemia. Moreover, side branch ligation (SBL) mitigated signs and symptoms of HAIDI …”