Portal Steal Syndrome From a Large Linton’s Splenorenal Shunt after Liver Transplantation: Successful Endovascular Management Through Off-Label Application of a 30 mm Amplatzer Cardiac Plug

A 34-year-old patient underwent liver transplantation for progressive hepatic failure in the setting of congenital hepatic fibrosis. In past medical history, the patient had undergone splenectomy with proximal Linton’s splenorenal surgical shunt creation for symptomatic portal hypertension with hypersplenism. The patient developed an early allograft dysfunction, with radiologic evidence of a reduced portal flow associated to portal steal from the patent surgical shunt. The patient was successfully treated through endovascular placement of a 30 mm Amplatzer cardiac plug at the origin of the splenic vein.

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

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.

Subclavian Steal Syndrome Secondary to Atherosclerosis: A Case Report and Review of Literature

Subclavian Steal Syndrome (SSS) is a rare vascular syndrome caused due to proximal occlusion or stenosis of subclavian or innominate artery. It is usually asymptomatic but occasionally may present with vertebrobasilar insufficiency and/or upper limb ischemia. Atherosclerosis is the most common cause.

MILLER Banding Procedure for Treatment of Dialysis Access–Related Steal Syndrome, Pulmonary Hypertension, and Heart Failure

A Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) banding procedure has been used for treating patients with dialysis access–related steal syndrome (DASS) and high-flow vascular access–related pulmonary hypertension (PHT) and heart failure (HF). We performed a retrospective analysis of patients undergoing the MILLER procedure performed for DASS, HF, and PHT from our Vascular Access Database from September 2017 to October 2019. Outcomes included primary patency of banding, primary assisted patency, and secondary patency, using time-to-event analyses with Kaplan-Meier curves and life tables to estimate 6- and 12-month rates. A total of 13 patients (6 men and 7 women, mean age 60 ± 14 years) underwent the MILLER procedure, 6 patients for DASS and 7 patients for pulmonary hypertension and heart failure (PHT/HF). Technical success was achieved in all patients. The longest duration of follow-up was 28 months (median 12 months [IQR 7, 19]). One patient died at 1 month after the intervention due to stroke. One patient developed access thrombosis of the graft 3 days after the procedure. Repeat banding was required in 1 patient 8 months after the first procedure. The 6-month primary patency rate of banding following this procedure was 83% while the 12-month rate was 66%. The 6- and 12-month secondary patency rates were 87% and 75%, respectively. The MILLER procedure can be performed for DASS and PHT/HF with improvement of symptoms and good long-term patency rates. Additional interventions to maintain patency and efficacy are required on long-term follow-up.

The importance of ultrasonography in surgical treatment of vascular access for hemodialysis complications

Background. Most complications of vascular access for hemodialysis require surgical treatment and if ineffective lead to fistula loss and depletion of the vascular resource for the new fistula creation.Objective. To identify complications of permanent vascular access for hemodialysis which require surgical treatment and evaluate its results using duplex scanning.Design and methods. Ultrasonography, clinical and laboratory examinations were performed in 550 patients undergoing hemodialysis.Results. Complications of vascular access for hemodialysis were detected in 154 (28.0 %) patients, surgical treatment was performed in 96 (62.3 %) patients. The main indications for surgical treatment were: significant stenosis, occlusive thrombosis, non-occlusive thrombosis in combination with significant vein stenosis, aneurysm with increased access flow, ischemic steal syndrome of the hand and pulsating hematoma. The analysis of surgical interventions showed that the creation of a new access was more often performed (41.7 %) compared to other types of fistula reconstructions which leads to a decrease in the number of vessels in the upper extremities that can be used to create access in the future.Conclusion. Duplex ultrasound allows diagnosing vascular access for hemodialysis complications and evaluating the results of their surgical treatment.