Vertebral and internal mammary artery steal syndrome in patients with hemodialysis access

Abstract

Summary:Background: Increased fl ow in the subclavian artery feeding a vascular access for hemodialysis can induce steal phenomena in the vertebral (VA) and internal mammary artery (IMA). The aim of this study was to describe the hemodynamic effects of access fl ow on the VA and IMA in patients with native fi stulas and grafts. Patients and methods: Peak systolic (PSV) and end diastolic (EDV) velocity measurements of the VA, IMA and carotid arteries, as well as fl ow volume measurements of the subclavian artery, were performed. Flow measurements at the side of the vascular access were compared with the contralateral side. Fifty-fi ve patients were consecutively included, most with a radio-cephalic fi stula on the left arm with a mean shunt volume of 1156 ml/min. Results: Pathologic fl ow patterns were observed in the ipsilateral VA in four patients (7.3 %); contralateral VA fl ow was normal in all patients. Peak systolic velocity of the VA was signifi cantly decreased at the side of the shunt arm with a PSV of 42.6 ± 11.8 cm/s compared to 48.4 ± 15.6 cm/s contralateral (p < 0.05). The IMA fl ow pattern were normal in all patients. The PSV of the IMA was signifi cantly decreased (p < 0.01) at the side of the shunt arm (87.5 ± 29.1 cm/s) compared to the non-shunt arm (95.9 ± 27.4 cm/s). Conclusion: We describe signifi cant hemodynamic effects of fi stulas to the vertebral and internal mammary arteries. Doppler spectral analysis of the vertebral and internal mammary arteries should be integrated in ultrasound, especially in patients with cerebrovascular or cardiac symptoms.

Screening for subclinical subclavian artery stenosis before coronary artery bypass grafting: Should we do it?

“…32,33 Even moderate subclavian stenosis can be hemodynamically significant when myocardial demand increases or when upper extremity flow demand increases particularly in hemodialysis patients with ipsilateral arteriovenous fistula. 34 The treatment options for subclavian artery stenosis include surgical bypass, percutaneous angioplasty, and stenting. 35,36 While surgical bypass has previously been the favored option, good initial success rates and effective long-term primary patency with endovascular stenting have established percutaneous therapy as the favored approach.…”