Arterial Steal Syndrome: A Modest Proposal for an Old Paradigm

Arterial Steal Syndrome: A Modest Proposal for an Old Paradigm Arif Asif, MD, Carlos Leon, MD, Donna Merrill, RN, Bhagwan Bhimani, MD, Renee Ellis, MD, Marco Ladino, MD, and Florin N. Gadalean, MD ● Background: Access ligation has been considered to be the treatment for patients presenting with arterial steal syndrome by many nephrologists. We report results of a prospective study using comprehensive arteriography coupled with percutaneous transluminal balloon angioplasty (PTA) or surgical intervention to evaluate and manage steal syndrome. Methods: Twelve consecutive patients referred for symptoms of steal syndrome were examined. Comprehensive arteriography of the extremity to diagnose arterial stenoses and delineate anatomy was performed by advancing a diagnostic catheter into the subclavian artery. Findings of arteriography and degrees of stenosis before and after PTA also were documented. Resolution of symptoms after PTA and surgical interventions, as well as complications, were recorded. Results: Angiography showed arterial stenotic lesions in 10 of 12 patients (83%). The degree of stenosis was 66% ⴞ 14% (SD). Eight patients (80%) with stenotic lesions underwent PTA successfully. The degree of stenosis after PTA was 13% ⴞ 10%. The remaining 2 patients were not considered candidates for PTA and were referred to surgery with arteriography images. One patient underwent ligation and the other patient required an axillary loop fistula using the same outflow vein. The 2 patients without stenoses showed excessive steal through the anastomosis and underwent lengthening procedures by insertion of a vein segment. All 12 patients are symptom free with a mean follow-up of 8.3 ⴞ 4 months, and 11 of 12 patients (92%) are dialyzing using the same access. There were no procedure-related complications. Conclusion: We suggest that complete imaging of the arterial circulation of the extremity be considered in patients presenting with symptoms of steal syndrome to properly assess the arterial anatomy and develop a treatment strategy. Am J Kidney Dis 48:88-97. © 2006 by the National Kidney Foundation, Inc. INDEX WORDS: Arterial steal syndrome; arterial stenosis; arteriovenous fistula; interventional nephrology; balloon angioplasty.

A

RTERIAL STEAL SYNDROME is an important complication in patients receiving long-term hemodialysis (HD) using an arteriovenous access. Depending upon the definition used, the prevalence of this complication varies from 1% to 20%.1-5 It is more common in patients with proximal (brachial artery–based) than distal (radial artery–based) accesses.2 The syndrome usually manifests as hand pain (on and off dialysis) and, less frequently, loss of distal function and tissue death. Although it results in access loss, ligation of the arteriovenous access has been considered to be the treatment by many nephrologists. At a conceptual level, the goal for From Interventional Nephrology, Division of Nephrology, University of Miami Miller School of Medicine, Miami, FL. Received December 13, 2005; accepted in revised form March 28, 2006. Originally published online as doi:10.1053/j.ajkd.2006.03.077 on June 5, 2006. Support: This project was not supported by any grants or funding agencies. Potential conflicts of interest: None. Address reprint requests to Arif Asif, MD, Director, Interventional Nephrology, Associate Professor of Medicine, University of Miami Miller School of Medicine, Miami, FL. E-mail: [email protected] © 2006 by the National Kidney Foundation, Inc. 0272-6386/06/4801-0010$32.00/0 doi:10.1053/j.ajkd.2006.03.077 88

managing this complication must focus on augmenting blood flow distal to the access to relieve ischemia while preserving the lifeline of the patient. Pathophysiologic mechanisms governing steal syndrome are complex and poorly understood. Whereas shunting of blood to a low resistance area (arteriovenous access) resulting in hypoperfusion distal to the anastomosis has been suggested to be the cause, increased resistance to blood flow offered by the presence of arterial stenosis also can have a critical role.2,6 Recent data have emphasized that significant (ⱖ50%) arterial stenoses are seen commonly in dialysis patients presenting with symptoms of arterial steal6-8 or vascular access dysfunction.9-11 Although many reports have accentuated surgical interventions, including access ligation, banding/ plication, tapered graft insertion, distal revascularization-interval ligation, and revision using distal inflow procedure,6,12-17 only a few mentioned the importance of stenotic lesions in patients with arterial steal.6-8 This study presents a systematic application of a percutaneous approach in the management of patients with arterial steal syndrome and suggests an algorithm to manage patients presenting with this complication.

American Journal of Kidney Diseases, Vol 48, No 1 (July), 2006: pp 88-97

MANAGEMENT OF ARTERIAL STEAL

METHODS

Settings and Study Design From July 2004 to November 2005, a total of 12 of 372 long-term HD patients (3.2%; receiving HD on an outpatient basis) presented with symptoms of arterial steal (hand pain on and/or off dialysis). Physical examination was performed in all patients before and after the corrective intervention. Complete arteriography was performed to document arterial anatomy and to ascertain the presence of stenotic lesions on the arterial side. Percutaneous transluminal balloon angioplasty (PTA) was performed to treat the stenosis, when indicated. Those who were not considered candidates for angioplasty based on imaging were referred to a vascular surgeon. A hard copy of images and the arteriography report were sent to the surgeon. The plan and findings of arteriography for each patient were discussed with the surgeon. The management plan also was shared with the referring nephrology team. All patients were followed up prospectively. Local institutional review board approval was obtained for this study. All study procedures were carried out in accordance with the Declaration of Helsinki regarding research involving human subjects.

Physical Examination Physical examination included inspection for trophic changes and determination of extremity temperature by palpation. In addition, pulse volume by using simple palpation was recorded both with and without occlusion of the arteriovenous access and compared with the contralateral side. Finally, capillary refill was also determined.

Description of Angiography and Angioplasty Diagnostic arteriography was performed by cannulating the access in a retrograde direction and advancing a diagnostic catheter into the subclavian artery. Positioning of the diagnostic catheter in the subclavian artery to image the arterial circulation of the upper extremity was based on previous descriptions by Khan and Vesely.10 Complete evaluation of the extremity arteries was performed from the subclavian artery to the palmar arch. Images were recorded by using digital subtraction angiography in multiple planes, including orthogonal views. Angiographic images with and without occlusion of the access were obtained. Stenosis of 50% or greater narrowing of the luminal diameter compared with adjacent normal segment was considered significant. Angioplasty was performed by using a standard technique.18 Low-pressure balloons (Classique; ultrathin diamond; Boston Scientific, Natick, MA) were used to perform angioplasty. The size of the balloon never exceeded the size of the artery in which angioplasty was being performed. A brachial artery approach to perform angiography or angioplasty was not needed and never was performed.

Parameters Recorded Demographic characteristics of the 12 study patients were analyzed. Locations of arterial stenoses were recorded. Procedure success, defined by disappearance of symptoms, and

89 Table 1. Demographic Characteristics of Patients With Arterial Steal Syndrome No. of patients Age (y) Sex Males Race/ethnicity African American Hispanic Haitian Type of access Arteriovenous fistula Brachiocephalic Arteriovenous graft Brachiobasilic loop Smoking Cause of end-stage renal disease Hypertension Diabetes Glomerulonephritis Polycystic kidney disease

12 52 ⫾ 11 7 (64) 7 (58) 3 (25) 2 (17)

8 (67) 4 (33) 7 (58) 6 (50) 3 (25) 2 (17) 1 (8)

NOTE. Results expressed as mean ⫾ SD, number, or number (percent).

procedure-related complications were recorded. Data are reported as mean ⫾ SD.

RESULTS

Demographic characteristics of the study patients show that more than 60% of patients were men. Mean age was 52 ⫾ 11 years (range, 31 to 66 years; Table 1). African Americans and Haitians comprised 81% of the study population. Hypertension was the most common cause of end-stage renal disease (45%), followed by diabetes (36%). Eight patients were receiving dialysis therapy using an arteriovenous fistula, whereas 4 patients had an arteriovenous graft. No patient had a radiocephalic fistula. Additionally, no patient in this study had duplex brachial/radial artery or forearm pressure measurements before fistula creation, and no records of simple blood pressure measurements to compare the difference between the upper extremities before access creation were available. Physical examination showed a cold extremity compared with the other side in all 12 patients. Trophic changes were found in no patient. Brachial arterial pulses examined at midarm level were equal on both sides in all patients. Radial artery pulse was absent in all patients with steal syndrome without occlusion of the arteriovenous access, except for 1 patient. With occlusion, 10

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Complete arteriography

Arterial stenosis Present n=10*

Absent n=2

Interventions

Percutaneous Intervention n= 8

Surgical Intervention n=4

Resolution of symptoms n=8

Resolution of symptoms n=4

Access preservation n=8

Access preservation n=3

of the 11 patients with absent pulse showed a feeble pulse, whereas 1 patient did not develop a radial pulse even after this maneuver. Capillary refill was difficult to assess and delayed (⬎4 seconds) in all patients with or without occlusion of the access. Technical Success Arteriography results are shown in Fig 1. Angiography showed arterial stenotic lesions in

Fig 2. (A) An axillary artery stenosis (70%). (B) Successful dilatation of the stenotic lesion after balloon angioplasty with resolution of symptoms of steal syndrome.

Fig 1. Results of arteriography in 12 consecutive patients undergoing arteriography. *Two patients with arterial stenosis were referred for surgical intervention.

10 of 12 patients (83%). The degree of stenosis was 66% ⫾ 14% (range, 50 to 90). Locations of stenoses included axillary artery lesion (n ⫽ 1; Fig 2), brachial artery upstream from the anastomosis (n ⫽ 5), and arterial lesions at the anastomosis (n ⫽ 4; Fig 3). Two patients (17%) with steal syndrome did not show stenosis (Fig 4). Eight of the 10 patients (80%) with stenotic lesions underwent PTA successfully. The degree of stenosis after angioplasty was 13% ⫾ 10%

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Fig 3. Brachiocephalic fistula with (A) critical stenosis of the brachial artery in the anastomotic area and (B) successful angioplasty of the lesion.

(range, 0 to 40). Five patients showed residual lesions ranging from 10% to 40%. The remaining 2 patients were not considered candidates for a percutaneous approach. One patient had a complete occlusion of the brachial artery distal to the

anastomosis and underwent an access ligation procedure. This patient had fistula creation on the contralateral side. The remaining patient had a variant brachial artery (Fig 5) and was referred to the surgeon for creation of an axillary loop fistula. The 2 patients without stenoses showed excessive flow through the anastomosis coupled with severe retrograde flow from a distal portion of the brachial artery into the fistula (Fig 4A). These patients successfully underwent lengthening procedures by insertion of a vein segment. Clinical Success Overall, 8 of 12 patients (67%) were treated successfully with percutaneous balloon angioplasty, whereas 4 of 12 patients (33%) required surgical intervention. Symptoms of arterial steal disappeared in all 12 patients immediately after intervention. At a mean follow-up of 8.3 ⫾ 4 months (range, 3 to 18 months), these patients remain symptom free. Eleven of the 12 patients (92%) are dialyzing using the same access. There were no procedure-related complications. DISCUSSION

Fig 4. (A) A patient with a brachial artery (arrow) to cephalic vein fistula with symptoms of arterial steal. Retrograde flow into the fistula was seen through the distal portion of the brachial artery. No flow distally past the arrowhead was seen on angiography. (B, C) Upon occlusion, antegrade flow was established into the forearm arteries (arrows).

Previous investigators have documented the presence of underlying obstructive arterial stenoses as a cause of peripheral ischemia in HD patients.6-8 Using comprehensive arteriography, these studies reported the incidence of arterial stenosis to range from 62% to 100%.6-8 In 1 study,7 complete arteriography from the aortic to the palmar arch was performed to assess the

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Fig 5. (A-F) Arteriography in a patient with symptoms of arterial steal syndrome. Arrows indicate the direction of blood flow. Bold arrow (short) indicates 60% stenosis of the artery just proximal to the anastomosis. Bold arrow (long) shows a juxta-anastomotic venous stenosis. Even this stenosis was not able to protect the patient against steal syndrome. Retrograde flow was noted through the radial artery into the access. Physical examination could confirm the retrograde filling of the radial artery by occluding the ulnar artery and performing palpation of the radial artery. The patient showed a good radial artery on physical examination. This case required an axillary loop fistula using the outflow of the existing fistula. Abbreviations: RA, radial artery; UA, ulnar artery; CVAVF, cephalic vein arteriovenous fistula.

presence of arterial stenosis in HD patients presenting with symptoms of peripheral ischemia (n ⫽ 13). In this analysis, 62% of the 13 patients referred for evaluation of symptoms of steal syndrome showed significant (ⱖ50%) arterial stenosis. Conversely, a separate report6 found stenosis in the inflow circulation in 100% of patients who underwent complete arteriography (n ⫽ 5). In the current study, the incidence of significant (ⱖ50%) arterial stenosis was 10 of 12 patients (83%). These results are in agreement with a recent study that reported an 80% incidence of arterial disease in patients presenting with arterial steal syndrome.8 Only a minority of patients (2 of 12 patients; 17%) with symptoms of arterial steal showed absence of arterial lesions in the present report. However, in this study, arteriography was performed by advancing a diagnostic catheter into the subclavian artery. The incidence of arterial stenosis might have been even greater if the imaging catheter was advanced into the aortic arch area to visualize proximal arteries. The presence of arterial stenosis can have a profound effect on the surgical procedure per-

formed to correct arterial steal. Recognition of these stenoses before planning a surgical procedure can be very important. For example, in the presence of significant arterial stenosis proximal to the anastomosis, a banding procedure applied to correct arterial steal can result in a critical decrease in access blood flow, culminating in access thrombosis. Such a scenario was documented by DeCaprio et al.6 In a retrospective analysis, these investigators reported 18 dialysis patients who presented with symptoms of arterial steal. Eleven of 18 patients (61%) underwent a banding procedure without a prior arteriography, with a 6-month patency rate of only 9%. Five of 18 patients (28%) underwent arteriography and documented an arterial inflow lesion. Of these 5 patients, 2 patients underwent angioplasty and stent insertion, with resolution of symptoms and continued patency of the access. One patient underwent graft ligation because of multiple arterial lesions. Of the remaining 2 patients, axillary artery stenosis could not be opened successfully in 1 patient and the graft thrombosed. The last

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Symptoms of arterial steal

Rule out other causes of hand pain: Carpel tunnel, diabetic neuropathy, etc Perform complete arteriography

Arterial stenosis present

Arterial stenosis absent

Stenoses amenable to angioplasty Yes Fig 6. A simple algorithm to manage patients with symptoms of arterial steal.

Consider PTA

patient with an arterial inflow lesion underwent a banding procedure without angioplasty. This graft thrombosed 2 days later. One of the 18 patients was lost to follow-up. This study highlights that the presence of unsuspected arterial stenosis might explain, at least in part, the dismal success6,12 of banding procedures performed to alleviate steal syndrome. In the present series, a combination of percutaneous and surgical interventions resulted in resolution of symptoms in 100% of patients, with access preservation in more than 90%. We treated arterial lesions, including arterial stenosis in the anastomotic area (Fig 3), with PTA. Lesions were approached through the arteriovenous access itself. Brachial artery puncture to perform angioplasty was not needed. Only the patient with complete occlusion of the brachial artery distal to the anastomosis required an access ligation procedure. Choice of the surgical procedure was based on the surgeon’s discretion. All 11 accesses are patent, and the patients are receiving dialysis therapy successfully using the same access with a mean follow-up of 8.3 ⫾ 4 months. In the present report, patients with stenotic lesions did not automatically qualify for angioplasty. Similarly, not all patients referred for steal underwent surgical intervention. Nevertheless,

No Surgical Intervention

all patients with symptoms of arterial steal were evaluated first by using arteriography (Fig 6). The management approach was based solely on the findings of arteriography. Instead of the common approach of focusing on limiting the flow through the access system and risking thrombosis, treatment strategies converged on improving distal perfusion, as well as preserving the existing access. Patients underwent either ligation or a lengthening procedure to increase resistance in the outflow of the fistula or angioplasty to improve overall inflow to the extremity. It is important to note that in a great majority of forearm and proximal arteriovenous accesses, clinically silent retrograde flow can be seen.19,20 Nevertheless, demonstration of retrograde flow does not predict or indicate the existence of a clinical steal syndrome.2,19 Likewise, hemodynamic evidence of arterial steal can be found in most patients; however, ischemic symptoms develop in only a minority. A variety of noninvasive investigations, such as digital blood pressure (DBP), digital/brachial index (DBI) measurement, digital plethysmography, duplex ultrasonography, and transcutaneous oxygen saturation determination, are available to assist in the management of patients with symptoms of arterial steal.21-26 In 1 study (n ⫽ 35), DBI less than 0.6 reasonably

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predicted, but still was not diagnostic for, the development of symptoms of arterial steal.21 In another report of 109 patients,22 DBI less than 0.6 to predict steal had specificity of only 59% and a positive predictive value of 18%. An absolute DBP or DBI value below which symptoms of steal were inevitable has not been validated and standardized in a prospective fashion.23 Using pulse oximeter, Halevy et al24 found an oxygen saturation of only 42% to 63% in 5 patients presenting with symptoms of arterial steal. Postintervention, these investigators documented an increase in oxygen saturation in all 5 patients (80% to 100%), with resolution of symptoms. However, the small sample size of the study is a major limitation of this study. Sumner26 has emphasized that measurement of DBP, DBI, and oxygen saturation requires extreme caution. Such studies should be performed in a warm (25°C) draft-free room with the patient relaxed. All efforts should be made to allay apprehension. Even in this scenario, some patients may remain vasoconstricted and require soaking the hand in warm water. In this way, vasoconstriction that can make the interpretation of results very difficult can be avoided. The operator must consider performing digital pressure in all fingers to localize the problem to digital versus palmar arch. Although noninvasive vascular laboratories are the correct place for the performance of most hemodynamic tests, this environment is not always present in most interventional suites. However, when performed accurately, hemodynamic evaluation can assist in the management of patients presenting with symptoms of arterial steal syndrome. Although all these interventions can assist in the management of patients presenting with symptoms of arterial steal, for the most part, indication to intervene is based solely on clinical grounds (ie, hand pain on and or off dialysis).25,27 In this context, this report has a limitation in that we did not perform these objective hemodynamic parameters before or after the procedure. Conversely, the current report deals with patients presenting with established symptoms of arterial steal and largely converges on resolution of symptoms postintervention. Intuitively, one could imagine that by performing physical examination, the cause of arterial steal would be disclosed. In this context, the

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appearance of a radial pulse with access occlusion would indicate that the arteriovenous access was stealing too much blood away from the forearm, creating ischemia, and flow reduction through the large anastomotic orifice was needed. Although logical, findings of the present study fail to support this notion. A majority (91%) of patients showed pulse with occlusion, yet only a minority (18%) of patients were candidates for a flow-reduction procedure through the access. Interestingly, 1 patient had a radial pulse without occlusion and, despite this, had symptoms of steal syndrome. This patient had retrograde flow through the radial artery to the fistula (Fig 3). Of interest, pulse examination in the patient with axillary artery stenosis did not indicate a difference in volume of the brachial artery pulse compared with the other side. We did not find capillary refill to be helpful. In retrospect, pulse oximetry compared with visual inspection might have been a better test to assess capillary refill. Although physical examination is emerging as one of the most valuable tools in the diagnosis of stenoses in dialysis access, its utility to differentiate between patients with and without arterial stenosis was less than optimal in the present report. However, the small sample size of the current series does not allow a firm conclusion for or against the use of physical examination in patients with arterial steal syndrome. In addition to arterial stenosis and excessive steal through the anastomosis, vascular calcification causing distal arteriopathy is an important factor that may contribute to the development of symptoms of arterial steal syndrome (Fig 7).28 Vascular calcification affects both intimal and media layers.29 Disturbances in mineral metabolism in the uremic milieu, calcium-containing phosphate binders and vitamin D treatment of secondary hyperparathyroidism, increased oxidized low-density lipoprotein cholesterol levels, increased oxidative stress, and hyperhomocysteinemia may contribute to the pathogenesis.28 Whereas PTA and surgical interventions offer an important role in the management of ischemia related to stenosis and excessive steal through the fistula, there is no definite therapy for this vascular calcification. Avoidance of treatment modalities that lead to calcium overload and achievement of good mineral metabolic balance

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Fig 7. A patient with a radiocephalic fistula. (A) Arrows indicate vascular calcification of forearm arteries. (B) The brachial artery of the same patient also shows calcification. Anastomosis (double arrow), imaging catheter into the fistula (arrowhead).

and optimal dialysis are the mainstay of treatment for vascular calcification. Symptoms of arterial steal have been highlighted to be common in patients with diabetes. Conversely, in this study, only 36% of patients had diabetes. However, 7 of 12 patients (58%) in the current report gave a history of active smoking, whereas 4 of 12 patients (34%) indicated they had not smoked for at least 6 months. Only 1 patient (8%) never smoked. Current and former smoking are associated with peripheral arterial disease.30,31 In addition, smoking increases the risk for amputation in patients with claudication32 and decreases patency rates after lower-extremity bypass.33 Foley et al34 showed in dialysis patients that current smoking was predictive of peripheral arterial disease and future cardiovascular events. Smoking cessation seems to result in an increase in exercise tolerance and ankle pressure in patients with intermittent claudication.35 In this context, smoking remains a modifiable risk factor. Consequently, smoking cessation should be encouraged strongly. Time from access creation to steal development generally is short, with steal immediately apparent after access creation. However, time of onset of symptoms of arterial steal in our study patients (who were already receiving long-term dialysis on an outpatient basis) was 8 ⫾ 2 months from the time of access creation. Duration of symptoms was 2 ⫾ 0.5 months. Although most mild cases of steal would resolve on their own with the development of collateral circulation, in this analysis, patients reported that symptoms

progressively increased in severity. Hand pain during dialysis was the most critical symptom found in this study (Table 2). In addition to arterial insufficiency, hand pain can be caused by carpal tunnel syndrome, tendopathies, and arthropathies, which can occur in long-term HD patients and mainly are influenced by ␤2-microglobulin amyloidosis.36 Carpal tunnel syndrome, caused by entrapment of the median nerve, is seen in a majority of patients. Diagnostic clues include pain in both hands because median nerve entrapment is bilateral in a large proportion of cases. Wasting of the lateral thenar muscles often is present at diagnosis, denoting advanced nerve compression.36-38 Electromyogram showing a decrease in motor conduction can help establish the diagnosis.37 Destructive arthropathy of the hands is common in long-term HD patients.39 This condition differs from deposition of amyloid in the joint because histological studies of the synovial membrane Table 2. Symptoms of Arterial Steal Symptom of Arterial Steal

Cold hand Hand pain at rest Hand pain during dialysis†

Severity of Symptoms

No. of Patients

Moderate Moderate to severe*

12 8

Moderate to severe*

12

*Patient reported progressive worsening of hand pain on and off dialysis. †Patients required early termination of dialysis because of hand pain frequency.

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and subchondral bone found no amyloid, even in patients with clinical or roentgenographic evidence of amyloidosis at other sites. Electron microscopy studies also failed to show crystals or amyloid.39 Destructive arthropathy of the hands in HD patients is not a manifestation of dialysisrelated amyloidosis. The pathophysiological process of the condition remains poorly understood. Deformities of phalangeal joints, instability, and localized tenderness are some of the features that assist in making the diagnosis of this entity. Joint space obliteration and subchondral erosions are seen on radiographic examination. Another condition that can result in hand pain after arteriovenous access creation is reflex sympathetic dystrophy syndrome.40 This syndrome is characterized by pain and swelling of an affected extremity, most commonly seen after trauma. Reflex sympathetic dystrophy syndrome should be included in the differential diagnosis of unexplained limb pain coupled with swelling after arteriovenous access placement. Although mostly symmetrical, diabetes can involve isolated limb nerves and cause pain.41 However, ischemic monomelic neuropathy is a complication of vascular access observed almost exclusively in patients with diabetes, particularly those with preexisting neuropathy.20,42 The entity is characterized by the development of acute pain, weakness, and paralysis of forearm and hand muscles. There often is sensory loss accompanied with motor. The condition occurs soon (minutes to hours) after creation of an arteriovenous access. The condition results from ischemic infarction of the vasa nervosa. Ischemic monomelic neuropathy can be diagnosed clinically based on acute onset of pain after access creation with a history of diabetes and dominant neurological symptoms and signs. The hand is warm, and the radial pulse variably is present. Good vascular surgery support is critical. The value of working with a vascular surgeon who has a full repertoire of surgical skills and procedures that allow the application of highly innovative solutions to difficult anatomic problems cannot be overemphasized. The surgeon, interventionalist, and referring nephrologist must work together to plan an optimal strategy for a given situation. In conclusion, significant arterial stenoses in dialysis patients with an arteriovenous access are a reality. We suggest that complete imaging of the arterial circulation of the extremity be considered

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in long-term dialysis patients presenting with symptoms of arterial steal. We propose that planning and application of corrective procedures must take into account the findings of arteriography. A team approach among nephrologists, interventionalists, and surgeons would only improve patient care. REFERENCES 1. Morsy A, Kulbaski M, Chen C, Isiklar H, Lumsden AB: Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure. J Surg Res 74:8-10, 1998 2. Tordoir JHM, Dammers R, van der Sande FM: Upper extremity ischemia and hemodialysis vascular access. Eur J Vasc Endovasc Surg 27:1-5, 2004 3. Haimov M, Baez A, Neff M, Sliftin R: Complications of arteriovenous fistulae for hemodialysis. Arch Surg 110: 708-712, 1975 4. Rinnaert P, Struyvan J, Mathieu J: Intermittent claudication of the hand after creation of an arteriovenous fistula in the forearm. Am J Surg 139:838-843, 1980 5. Miles AM: Upper limb ischemia after vascular access surgery: Differential diagnosis and management. Semin Dial 13:312-315, 2000 6. DeCaprio JD, Valentine RJ, Kakish HB, Awad R, Hagino RT, Claggett GP: Steal syndrome complicating hemodialysis access. Cardiovasc Surg 5:648-653, 1997 7. Valji K, Hye RJ, Roberts AC, Oglevie SB, Ziegler T, Bookstein JJ: Hand ischemia in patients with hemodialysis access grafts: Angiographic diagnosis and treatment. Radiology 196:697-701, 1995 8. Guerra A, Raynaud A, Beyssen B, Pagny JY, Sapoval M, Angel C: Arterial percutaneous angioplasty in upper limbs with vascular access devices for haemodialysis. Nephrol Dial Transplant 17:843-851, 2002 9. Asif A, Gadalean FN, Merrill D, et al: Inflow stenosis in arteriovenous fistulas and grafts: A multicenter, prospective study. Kidney Int 67:1986-1992, 2005 10. Khan FA, Vesely TM: Arterial problems associated with dysfunctional hemodialysis grafts: Evaluation of patients at high risk for arterial disease. J Vasc Interv Radiol 13:1109-1114, 2002 11. Lockhart ME, Robbin ML, McNamara MM, Allon M: Association of pelvic arterial calcification with arteriovenous thigh graft failure in haemodialysis patients. Nephrol Dial Transplant 9:2564-2569, 2004 12. Odland MD, Kelly PH, Ney AL, Andersen RC, Bubrick MP: Management of dialysis-associated steal syndrome complicating upper extremity arteriovenous fistulas: Use of intraoperative digital photoplethysmography. Surgery 110:664-669, 1991 13. Schild AF, Pruett CS, Newman MI, et al: The utility of the VCS clip for creation of vascular access for hemodialysis: Long-term results and intraoperative benefits. Cardiovasc Surg 9:526-530, 2001 14. Rivers SP, Scher LA, Veith FJ: Correction of steal syndrome secondary to hemodialysis access fistulas: A simplified quantitative technique. Surgery 112:593-597, 1992

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