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Distalization of the Anastomosis: An Effective Treatment for Dialysis Access–Associated Steal Syndrome
Distalization of the Anastomosis: An Effective Treatment for Dialysis AccesseAssociated Steal Syndrome Lorraine Corfield,1 Juanita Muller,1 Jo Ryan,2 and Rick Bond,1 Perth, Western Australia
Steal syndrome after arteriovenous fistula formation for dialysis access can cause ischemic pain and tissue loss. This is an indication for surgical revision, usually either banding (or ligation) or the distal revascularisation and interval ligation procedure. However, banding is inexact, and distal revascularisation and interval ligation can further compromise the arterial supply to the arm. We report three cases in which an alternative approach of moving the arteriovenous anastomosis distally was used, thereby protecting arterial inflow to the hand. In all three cases, the steal resolved and the fistula remained patent.
Steal syndrome is a complication of arteriovenous fistula formation. It may occur frequently but is rarely persistent or severe. However, in some patients, it causes debilitating symptoms of ischemic rest pain and tissue loss. The risk of developing steal syndrome increases when the brachial artery, as opposed to distal vessels, is used for inflow and when preexisting arterial disease is present. The two most common surgical methods of reversing steal syndrome involve restriction of venous outflow by means of a ligature or band applied to the draining vein1 or by ligation of the brachial artery and bypassdthe distal revascularisation and interval ligation (DRIL) procedure (Fig. 1).2 Banding the venous outflow is a compromise between ligating tightly enough to prevent steal without occluding the fistula. It also further reduces the available length of vein for puncture. DRIL introduces the risk of compromising the arterial supply to
1 Department of Vascular Surgery, Fremantle Hospital, Perth, Western Australia. 2 Vascular Access Nurse, Fremantle Hospital, Perth, Western Australia.
Correspondence to: Lorraine Corfield, MBBS, BSc, MA, FRCS (Eng), Department of Vascular Surgery, Fremantle Hospital, Alma Street, Fremantle, Perth 6160, Western Australia; E-mail: [email protected] Ann Vasc Surg 2012; 26: 572.e11e572.e13 DOI: 10.1016/j.avsg.2011.11.024 Ó Annals of Vascular Surgery Inc. Published online: February 10, 2012
the arm. Upper-limb amputation is a recognized, albeit rare, outcome of this procedure.3 We report three cases of our preferred technique for management of steal syndrome. The principle involves moving the anastomosis to the radial or ulnar artery by inserting a jump graft (Fig. 2). The important requirements for this are as follows: 1. Two patent forearm vessels (one of which may be the interosseus vessel). 2. No untreated proximal arterial stenotic disease. 3. Fistula formation at a suitable distance from the bifurcation of the brachial artery. We aim for an arbitrary distance of 5 cm.
CASE REPORTS Case 1 A 70-year-old man with diabetic nephropathy underwent formation of a left brachiobasilic fistula. He subsequently developed numbness and coldness in his left hand at night and while on dialysis. To treat the steal, the fistula was ligated on the venous side and the radial artery used as inflow. A section of great saphenous vein was used to connect the already arterialized basilic vein to the radial artery (in a similar fashion to the brachiocephalic distalization shown in Fig. 2). The fistula matured well and was working with good effect within 6 weeks (blood flow rate: 315 mL/min, inflow pressure: 170 mm Hg, outflow pressure: +150 mm Hg). 572.e11
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Annals of Vascular Surgery
Fig. 3. The ischemic ulcer in case 3.
Fig. 1. The distal revascularisation and interval ligation procedure. (A) Ligation of brachial artery distal to fistula. (B) Arteriovenous fistula (AVF). (C) Replacement conduit (vein or graft). (D) Radial arterydnew AVF.
Fig. 4. The ulcer in case 3 after distalization of the arterial anastomosis. Because of steal symptoms, the fistula was not used and she continued to dialyze through a central venous catheter while revision was undertaken. Her left hand was cold and painful, with oxygen saturation levels of 89% compared with 99% in the right arm. A year after initial brachiocephalic fistula formation, the fistula was revised using the procedure in Figure 2. This resolved the steal symptomsdthe hand was immediately warm and well perfused, with full resolution of the pain. A month later, she had a successful cadaveric renal transplant. At the time of transplant, the fistula was functional. Case 3 Fig. 2. The revision using distal inflow procedure. (A) Brachial artery. (B) Ligation of AVF. (C) Replacement conduit. (D) New distal AVF. Case 2 A 63-year-old woman with immunoglobulin A nephropathy had a left brachiocephalic fistula created.
A 56-year-old woman with diabetic nephropathy had a left brachiocephalic fistula created for future dialysis. Within a month, she developed ischemic pain in her left fingers. At 11 months, the skin over the hypothenar eminence of her left hand ulcerated (Fig. 3). Occlusion of the fistula increased flow clinically in the radial artery. The fistula was, therefore, ligated on the venous side. The median cubital vein, rather than the true cephalic vein, had been used for the initial fistula,
Vol. 26, No. 4, May 2012
and the cephalic vein was, therefore, still in continuity. This was of good caliber and was used to create a radiocephalic fistula in the proximal forearm. At 1 month, the pain was improved, the ulcer healing (Fig. 4), and the fistula functioning.
DISCUSSION Brachial fistula ligation at its origin on the venous side with extension of the anastomosis to the proximal ulnar or radial artery to correct steal syndrome was first reported in a series of four patients in 2005 (revision using distal inflow [RUDI]).4 This completely resolved the steal in three cases. The fourth case had some improvement in steal symptoms but ongoing ischemic neuropathy. More recently, a case series of seven patients showed promising results, with steal symptoms resolving in all seven cases, albeit at the expense of the fistula in three.5 Schanzer reported good results from the ‘‘distal re-vascularisation and interval ligation procedure’’ (DRIL), with 83% of 42 resulting in complete relief of steal symptoms. However, at least one patient in this series ultimately required a forearm amputation.3 A key benefit of distalization of the arterial inflow of the fistula or the RUDI procedure is that the arterial inflow to the limb remains in line and does not rely on a bypass graft. This may be particularly relevant to those with tissue loss, where the limb may be threatened by ongoing steal.
Case reports 572.e13
Both DRIL and RUDI have the disadvantage that a (albeit small) section of conduit must be found to extend the vein. Banding of the outflow vein has the advantage that no new conduit is required, but its application is inexact and has a high incidence of failure of the fistula or lack of resolution of symptoms.
CONCLUSION The successful resolution of the steal in the three cases reported here adds weight to the published reports concluding that distalization of the arterial anastomosis is an effective treatment for dialysis accesseassociated steal syndrome. REFERENCES 1. DeCaprio JD, Valentine RJ, Kakish HB, et al. Steal syndrome complicating hemodialysis access. Cardiovasc Surg 1997;5: 648e53. 2. Schanzer H, Sklandany M, Haimov M. Treatment of angioaccess-induced ischemia by revascularization. J Vasc Surg 1992;16:861e4. 3. Minion DJ, Moore E, Endean E. Revision using distal inflow: a novel approach to dialysis eassociated steal syndrome. Ann Vasc Surg 2005;19:625e8. 4. Callaghan CJ, Mallik M, Sivaprakasam R, et al. Treatment of dialysis access-associated steal syndrome with the ‘‘revision using distal inflow’’ technique. J Vasc Access 2011;12: 52e6. 5. Schanzer H, Eisenberg D. Management of steal syndrome resulting from dialysis access. Sem Vasc Surg 2004;17:45e9.
Steal syndrome after arteriovenous fistula formation for dialysis access can cause ischemic pain and tissue loss. This is an indication for surgical revision, usually either banding (or ligation) or the distal revascularisation and interval ligation procedure. However, banding is inexact, and distal revascularisation and interval ligation can further compromise the arterial supply to the arm. We report three cases in which an alternative approach of moving the arteriovenous anastomosis distally was used, thereby protecting arterial inflow to the hand. In all three cases, the steal resolved and the fistula remained patent.
Steal syndrome is a complication of arteriovenous fistula formation. It may occur frequently but is rarely persistent or severe. However, in some patients, it causes debilitating symptoms of ischemic rest pain and tissue loss. The risk of developing steal syndrome increases when the brachial artery, as opposed to distal vessels, is used for inflow and when preexisting arterial disease is present. The two most common surgical methods of reversing steal syndrome involve restriction of venous outflow by means of a ligature or band applied to the draining vein1 or by ligation of the brachial artery and bypassdthe distal revascularisation and interval ligation (DRIL) procedure (Fig. 1).2 Banding the venous outflow is a compromise between ligating tightly enough to prevent steal without occluding the fistula. It also further reduces the available length of vein for puncture. DRIL introduces the risk of compromising the arterial supply to
1 Department of Vascular Surgery, Fremantle Hospital, Perth, Western Australia. 2 Vascular Access Nurse, Fremantle Hospital, Perth, Western Australia.
Correspondence to: Lorraine Corfield, MBBS, BSc, MA, FRCS (Eng), Department of Vascular Surgery, Fremantle Hospital, Alma Street, Fremantle, Perth 6160, Western Australia; E-mail: [email protected] Ann Vasc Surg 2012; 26: 572.e11e572.e13 DOI: 10.1016/j.avsg.2011.11.024 Ó Annals of Vascular Surgery Inc. Published online: February 10, 2012
the arm. Upper-limb amputation is a recognized, albeit rare, outcome of this procedure.3 We report three cases of our preferred technique for management of steal syndrome. The principle involves moving the anastomosis to the radial or ulnar artery by inserting a jump graft (Fig. 2). The important requirements for this are as follows: 1. Two patent forearm vessels (one of which may be the interosseus vessel). 2. No untreated proximal arterial stenotic disease. 3. Fistula formation at a suitable distance from the bifurcation of the brachial artery. We aim for an arbitrary distance of 5 cm.
CASE REPORTS Case 1 A 70-year-old man with diabetic nephropathy underwent formation of a left brachiobasilic fistula. He subsequently developed numbness and coldness in his left hand at night and while on dialysis. To treat the steal, the fistula was ligated on the venous side and the radial artery used as inflow. A section of great saphenous vein was used to connect the already arterialized basilic vein to the radial artery (in a similar fashion to the brachiocephalic distalization shown in Fig. 2). The fistula matured well and was working with good effect within 6 weeks (blood flow rate: 315 mL/min, inflow pressure: 170 mm Hg, outflow pressure: +150 mm Hg). 572.e11
572.e12 Case reports
Annals of Vascular Surgery
Fig. 3. The ischemic ulcer in case 3.
Fig. 1. The distal revascularisation and interval ligation procedure. (A) Ligation of brachial artery distal to fistula. (B) Arteriovenous fistula (AVF). (C) Replacement conduit (vein or graft). (D) Radial arterydnew AVF.
Fig. 4. The ulcer in case 3 after distalization of the arterial anastomosis. Because of steal symptoms, the fistula was not used and she continued to dialyze through a central venous catheter while revision was undertaken. Her left hand was cold and painful, with oxygen saturation levels of 89% compared with 99% in the right arm. A year after initial brachiocephalic fistula formation, the fistula was revised using the procedure in Figure 2. This resolved the steal symptomsdthe hand was immediately warm and well perfused, with full resolution of the pain. A month later, she had a successful cadaveric renal transplant. At the time of transplant, the fistula was functional. Case 3 Fig. 2. The revision using distal inflow procedure. (A) Brachial artery. (B) Ligation of AVF. (C) Replacement conduit. (D) New distal AVF. Case 2 A 63-year-old woman with immunoglobulin A nephropathy had a left brachiocephalic fistula created.
A 56-year-old woman with diabetic nephropathy had a left brachiocephalic fistula created for future dialysis. Within a month, she developed ischemic pain in her left fingers. At 11 months, the skin over the hypothenar eminence of her left hand ulcerated (Fig. 3). Occlusion of the fistula increased flow clinically in the radial artery. The fistula was, therefore, ligated on the venous side. The median cubital vein, rather than the true cephalic vein, had been used for the initial fistula,
Vol. 26, No. 4, May 2012
and the cephalic vein was, therefore, still in continuity. This was of good caliber and was used to create a radiocephalic fistula in the proximal forearm. At 1 month, the pain was improved, the ulcer healing (Fig. 4), and the fistula functioning.
DISCUSSION Brachial fistula ligation at its origin on the venous side with extension of the anastomosis to the proximal ulnar or radial artery to correct steal syndrome was first reported in a series of four patients in 2005 (revision using distal inflow [RUDI]).4 This completely resolved the steal in three cases. The fourth case had some improvement in steal symptoms but ongoing ischemic neuropathy. More recently, a case series of seven patients showed promising results, with steal symptoms resolving in all seven cases, albeit at the expense of the fistula in three.5 Schanzer reported good results from the ‘‘distal re-vascularisation and interval ligation procedure’’ (DRIL), with 83% of 42 resulting in complete relief of steal symptoms. However, at least one patient in this series ultimately required a forearm amputation.3 A key benefit of distalization of the arterial inflow of the fistula or the RUDI procedure is that the arterial inflow to the limb remains in line and does not rely on a bypass graft. This may be particularly relevant to those with tissue loss, where the limb may be threatened by ongoing steal.
Case reports 572.e13
Both DRIL and RUDI have the disadvantage that a (albeit small) section of conduit must be found to extend the vein. Banding of the outflow vein has the advantage that no new conduit is required, but its application is inexact and has a high incidence of failure of the fistula or lack of resolution of symptoms.
CONCLUSION The successful resolution of the steal in the three cases reported here adds weight to the published reports concluding that distalization of the arterial anastomosis is an effective treatment for dialysis accesseassociated steal syndrome. REFERENCES 1. DeCaprio JD, Valentine RJ, Kakish HB, et al. Steal syndrome complicating hemodialysis access. Cardiovasc Surg 1997;5: 648e53. 2. Schanzer H, Sklandany M, Haimov M. Treatment of angioaccess-induced ischemia by revascularization. J Vasc Surg 1992;16:861e4. 3. Minion DJ, Moore E, Endean E. Revision using distal inflow: a novel approach to dialysis eassociated steal syndrome. Ann Vasc Surg 2005;19:625e8. 4. Callaghan CJ, Mallik M, Sivaprakasam R, et al. Treatment of dialysis access-associated steal syndrome with the ‘‘revision using distal inflow’’ technique. J Vasc Access 2011;12: 52e6. 5. Schanzer H, Eisenberg D. Management of steal syndrome resulting from dialysis access. Sem Vasc Surg 2004;17:45e9.