A new endovascular technique for the treatment of dialysis-associated steal syndrome

Vascular ◽  
2017 ◽  
Vol 26 (3) ◽  
pp. 335-337 ◽  
Author(s):  
Enrico Ascher ◽  
Jacob E. Mandel ◽  
Natalie A. Marks ◽  
Anil P. Hingorani
Keyword(s):  
Arteriovenous Fistula ◽  
Stent Graft ◽  
Brachial Artery ◽  
High Risk Patient ◽  
Arterial System ◽  
Dialysis Access ◽  
Endovascular Technique ◽  
Steal Phenomenon ◽  
Endovascular Approach ◽  
Steal Syndrome

Background Dialysis access-associated steal syndrome is a major complication of arteriovenous fistula creation whereby the low-resistance venous conduit shunts arterial inflow through the anastomosis, resulting in clinically significant distal artery insufficiency. Herein, we describe a case of severe steal phenomenon with gangrene of a digit following placement of an arteriovenous fistula that was treated with a novel, entirely endovascular technique. To our knowledge, this was the first totally endovascular approach to dialysis access-associated steal syndrome. Methods Catheterization of the right subclavian, axillary, and brachial arteries was performed. A short 5-Fr sheath was exchanged for a long destination 6-Fr sheath and placed in the proximal brachial artery. An arteriogram showed no stenosis of the arterial system, but did show substantial steal phenomenon with inflow to the arteriovenous fistula, instead of the forearm. We placed a stent graft in the brachial artery across the anastomosis such that the graft covered 3/4 of the length of the opening of the anastomosis. Results Immediately after placement of the stent graft the clinical picture improved dramatically. Patient was followed for 15 months after this procedure until her demise for unrelated causes without ever experiencing dialysis access-associated steal syndrome and with a patent and functional arteriovenous fistula. Conclusion We present a patient with severe dialysis access-associated steal syndrome complicated by third fingertip gangrene, which was successfully treated using a completely endovascular technique. This novel endovascular approach enabled a high-risk patient to avoid open surgery, preserve her limb, and maintain the function of her arteriovenous fistula.

Endovascular Treatment of Dialysis Access–Induced Hand Ischemia Using a Flared Stent-Graft

2017 ◽  
Vol 24 (5) ◽  
pp. 743-745 ◽  
Author(s):  
Chien Yi M. Png ◽  
William E. Beckerman ◽  
Peter L. Faries ◽  
David J. Finlay
Keyword(s):  
Stent Graft ◽  
Brachial Artery ◽  
Dialysis Access ◽  
Dialysis Patients ◽  
Hybrid Surgery ◽  
Hand Ischemia ◽  
Guide Catheter ◽  
Arterial Anastomosis ◽  
Endovascular Approach ◽  
Antegrade Flow

Purpose: To report an investigation of a purely endovascular procedure to address access-induced hand ischemia in dialysis patients. Case Report: Two dialysis patients presented with stage III steal syndrome consisting of severe pain and numbness in their fingers. Preoperative fistulograms distal to the anastomosis showed alternating antegrade and retrograde flow. Under ultrasound guidance, the fistula was accessed and a 4-F micropuncture sheath placed. An angled guidewire was then advanced proximally into the brachial artery. A 6-F short sheath with marker was placed followed by a 4-F straight guide catheter inserted into the proximal brachial artery. A 9-F Flair endovascular stent-graft was advanced over a 0.035-inch stiff angled Glidewire into the fistula just distal to the arterial anastomosis and deployed. Postoperatively, pain and numbness resolved in both patients immediately. Postoperative fistulograms documented antegrade flow. Access flow velocity readings decreased significantly and pulse oximetry readings increased significantly in both patients, who were followed for >6 months with no reported complications. Conclusion: These 2 cases suggest that this endovascular approach to access-induced hand ischemia may be a viable alternative to open/hybrid surgery.

Chronic Ischemic Monomelic Neuropathy after Arteriovenous Fistula Creation: A Unique Presentation of Vascular Steal

2020 ◽  
Vol 3 (2) ◽  
pp. 147-150
Author(s):  
Kaczynski RE ◽  
Asaad Y ◽  
Valentin-Capeles N ◽  
Battista J
Keyword(s):  
Arteriovenous Fistula ◽  
Complete Loss ◽  
Dialysis Access ◽  
Loss Of Function ◽  
Access Site ◽  
Surgical Ligation ◽  
Arteriovenous Access ◽  
Vascular Steal ◽  
Steal Syndrome

We discuss a case of a 58 year old male who presented for left upper extremity steal syndrome including ischemic monomelic neuropathy (IMN) 1.5 months after arteriovenous fistula creation. He presented after three surgical attempts to salvage his fistula with rest pain, complete loss of function with contracture of the 4th and 5th digits, and loss of sensation in the ulnar distribution for more than three weeks. At our institution, he underwent surgical ligation of the distal fistula and creation of a new fistula proximally, resulting in complete resolution of his vascular steal symptoms almost immediately despite the chronicity prior to surgical presentation. Our patient provides a unique perspective regarding dialysis access salvage versus patient quality of life. The patients’ functional status and pain levels should take precedence over salvage of an arteriovenous access site, and early ligation of the access should be completed prior to chronic IMN development. However, if a patient presents late along the IMN course, we recommend strong consideration of access ligation in order to attempt to regain the full neurovascular function of the extremity as we experienced in our patient.

Quantitative Evaluation of the Systemic Effects of Transposed Basilic Vein to Brachial Artery Arteriovenous Fistula: A Prospective Study

2008 ◽  
Vol 9 (4) ◽  
pp. 285-290 ◽  
Author(s):  
N. Saratzis ◽  
A. Saratzis ◽  
P.A. Sarafidis ◽  
N. Melas ◽  
K. Ktenidis ◽  
...  
Keyword(s):  
Blood Flow ◽  
Arterial Pressure ◽  
Arteriovenous Fistula ◽  
Cardiac Failure ◽  
Brachial Artery ◽  
Systemic Arterial Pressure ◽  
Flow Volume ◽  
Basilic Vein ◽  
Blood Flow Volume ◽  
Steal Syndrome

Background The transposed basilic vein to brachial artery arteriovenous fistula (BBAVF) constitutes an alternative autogenous vascular access (VA) site for chronic hemodialysis (HD); however, the hemodynamic effects of this procedure have not been adequately studied. The purpose of this study is to evaluate the effects of BBAVF on systemic arterial pressure, cardiac function, and upper limb ischemia (ischemic steal syndrome) utilizing reproducible quantitative methods. Methods Ten consecutive patients (eight males; mean age: 65.10 ± 2.87 yrs) scheduled to undergo a brachial-basilic vein transposition were included, excluding patients with cardiac failure. Blood flow volume at the level of the AVF, systemic arterial pressure (SAP), cardiac output (CO) and digital brachial index (DBI) were measured intra-operatively, before and after the creation of the BBAVF, and post-operatively on the 30th post-operative day and on the 3rd post-operative month. Results SAP and DBI at 30 days and 3 months post-operatively were significantly lower compared to baseline. CO at 30 days and 3 months post-operatively was significantly higher compared to baseline; however, none of the patients developed cardiac failure. DBI remained ≥0.6 at 3 months, except in one case (0.59). Blood flow volume at the level of the AVF was positively correlated with CO levels on the 30th post-operative day. Mean clinical follow-up was 12 months (range: 4–15 months). In two cases (20%) the AVF was thrombosed (4th and 10th post-operative month). Conclusion This prospective quantitative study proves that the BBAVF does impact significantly upon SAP, CO, and DBI; however, it is safe in terms of high-output cardiac failure and ischemic steal syndrome. The authors state that they do not have any commercial, proprietary, or financial interest in any products or companies described in this article.

Leg Ulcer as a Complication of a Posttraumatic Tibial Arteriovenous Fistula Treated by Endovascular Approach With Stent-Graft Placement

2012 ◽  
Vol 11 (3) ◽  
pp. 147-151 ◽  
Author(s):  
Martín Rabellino ◽  
Sergio Shinzato ◽  
Javier Aragón-Sánchez ◽  
Oscar Peralta ◽  
Ricardo Marenchino ◽  
...  
Keyword(s):  
Arteriovenous Fistula ◽  
Stent Graft ◽  
Leg Ulcer ◽  
Graft Placement ◽  
Endovascular Approach

scholarly journals Dialysis Access-Associated Steal Syndrome with Percutaneous Endovascular Arteriovenous Fistula Creation.

2021 ◽  
Author(s):  
Rakesh Varma ◽  
Manuel Betancourt-Torres ◽  
Eric Bready ◽  
Alian Al-Balas
Keyword(s):  
Risk Factors ◽  
Arteriovenous Fistula ◽  
Clinical Symptoms ◽  
Ulnar Artery ◽  
Renal Dysplasia ◽  
Dialysis Access ◽  
Hemodialysis Access ◽  
Vessel Occlusion ◽  
Flow Through ◽  
Steal Syndrome

Abstract Background: Dialysis access-associated steal syndrome is an infrequent complication after hemodialysis access creation. Clinical symptoms depend on the degree of steal. Mild symptoms include coldness, numbness and pain during dialysis. Severe steal can present with rest pain, cyanosis and ulcerations, and may require surgical ligation of the fistula. With recent advances in arteriovenous fistula creation, percutaneous endovascular arteriovenous fistula creation has demonstrated better maturation and patency rates with lower risk of wound healing and infection rates as compared to surgically created hemodialysis access. Percutaneous creation offers a minimally invasive alternative, though complications have been reported. The following presents the first described case of DASS following the use of percutaneous endovascular arteriovenous fistula creation, and discusses risk factors and management. Case Presentation: Our case is that of a 27-year-old male with end stage renal disease due to congenital renal dysplasia, who underwent left percutaneous arteriovenous fistula creation for initiation of dialysis. Two months after the procedure the patient complained of coldness, pain, tingling, and numbness in the left arm during dialysis, concerning for steal syndrome. The patient subsequently underwent brachial artery angiogram, which showed predominant flow through the fistula and minimal antegrade flow through the ulnar and interosseous arteries towards the hand, with a focal, severe stenosis in the distal ulnar artery. Angioplasty of the stenosis was performed, though steal symptoms continued. Conclusions: DASS, though rare, can be seen with percutaneous arteriovenous fistula creation. Identification of the risk factors prior to creation, especially in patients who are at higher risk of peripheral vascular disease, can help avoid this complication. Management is largely guided by clinical presentation. As long as there is adequate collateral supply to the extremity, single vessel occlusion is not a contraindication to percutaneous arteriovenous fistula creation with the use of WavelinQ technology. Careful patient selection with pre-creation angiogram may reduce the risk of symptomatic steal.

Brachial Artery Flow Assessment by Duplex Ultrasound Predicts Dialysis Access Steal Syndrome

2017 ◽  
Vol 43 ◽  
pp. 50
Author(s):  
John Lane ◽  
Tazo Inui ◽  
Andrew Barleben ◽  
Eugene Golts
Keyword(s):  
Brachial Artery ◽  
Duplex Ultrasound ◽  
Dialysis Access ◽  
Artery Flow ◽  
Steal Syndrome

A percutaneous endovascular technique for reducing arteriovenous fistula flow

2019 ◽  
Vol 21 (2) ◽  
pp. 251-255
Author(s):  
Joon Ho Hong
Keyword(s):  
Arteriovenous Fistula ◽  
Stent Graft ◽  
Skin Incision ◽  
Target Area ◽  
Shape Constraint ◽  
Effective Reduction ◽  
Arteriovenous Access ◽  
Endovascular Approach ◽  
Open Surgical Procedure

Reduction of arteriovenous access flow is usually performed by tightening the inflow lumen through an open surgical procedure. A percutaneous endovascular approach can provide a precise and effective reduction of access flow without making a skin incision. After placing a vascular introducer sheath toward the inflow direction of an arteriovenous fistula, a small stent (5 mm diameter × 25 mm length) was deployed in the target area near the anastomosis. A second stent (10 mm × 60 mm) was then deployed inside the first stent, making a corset-shape constraint on the access flow. This newly described endovascular procedure was utilized to reduce the excessive flow of arteriovenous fistula in three patients. Deployment of the constrained stent-graft resulted in reducing the estimated access flow from 1900, 1600, and 1500 mL/min to 1100, 900, and 900 mL/min, respectively. Percutaneous endovascular placement of a constrained stent-graft can narrow the inflow lumen of arteriovenous access to a desired precise diameter of 5 mm and effectively reduce access flow over a long-term period.

Preoperative Ultrasound Assessment for Dialysis Access Placement

2005 ◽  
Vol 29 (3) ◽  
pp. 131-136
Author(s):  
M. Ann Needham
Keyword(s):  
Renal Failure ◽  
Arteriovenous Fistula ◽  
Flow Diagram ◽  
Dialysis Access ◽  
Venous Outflow ◽  
The Status ◽  
Arterial Inflow ◽  
History Of ◽  
Ultrasound Assessment ◽  
Steal Syndrome

Vascular access includes any form of cannulation of arteries or veins. For the treatment of chronic renal failure, this term refers to the ability to access both the arterial inflow and the venous outflow for the purpose of replacing the function of the kidney. This work provides a brief review of the history of hemodialysis and presents the method we use currently to map the arterial and venous system prior to placement of an arteriovenous fistula. The purpose is to present the process we use to determine the status of the arteries and the venous patency, as well as the flow diagram we use to determine the steps taken for each patient referred for preoperative vein mapping, including the worksheet used to collect the information for the surgeon. This work presents the minimum prerequisites that are thought to be necessary to create a viable arteriovenous fistula. A brief discussion of the criteria and protocol is presented that is used to diagnose steal syndrome from the hand. Billing codes are included when this procedure is used.

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