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Neurologic and ischemic complications of upper extremity vascular access for dialysis
Neurologic and Ischemic Complications of Upper Extremity Vascular Access for Dialysis Anne B. Redfern, MD, Neal B. Zimmerman, MD, Baltimore, MD This study reviews the clinical course of 22 patients with chronic renal failure on hemodialysis with ischemic or neurologic problems in the upper extremity distal to an arteriovenous fistula. Twodistinct presentations were observed. Twelve patients developed significant motor and/ or sensory impairment immediately following surgical construction of the fistula. Ten patients presented with upper extremity ischemia, established or impending tissue loss, or nonhealing wounds distal to a dialysis fistula. Seventeen of the 22 patients were diabetic. Nerve conduction studies, noninvasive vascular studies, and arteriography were used to confirm the diagnosis. Sixteen of the 22 patients had ligation or revision of the fistula. Five patients underwent amputations at the metacarpal or phalangeal level, and one patient underwent below-elbow amputation. (J Hand Surg 1995;20A:199-204.)
More than 200,000 people in the United States are currently under t r e a t m e n t for end-stage renal disease. In 1990, 120,000 of the patients were treated with hemodialysis via surgically created arteriovenous fistulas, ~ T h e h e m o d y n a m i c a l t e r a t i o n s o f a proximal arteriovenous fistula can cause neurologic or ischemic p r o b l e m s in the extremities of patients with renal failure. T h e s e c o m p l i c a t i o n s are e s p e cially prevalent in persons with diabetes, w h o frequently h a v e preexisting peripheral n e u r o p a t h y and/ or occlusive peripheral vascular disease.
Materials and Methods B e t w e e n 1985 and 1992, 22 patients were treated for neuropathic or ischemic p r o b l e m s in their u p p e r extremities following arteriovenous fistula creation for hemodialysis. T w o distinct clinical presentation were identified. From the Raymond M. Curtis Hand Center, The Union Memorial Hospital, and Johns Hopkins University School of Medicine, Baltimore, MD. Received for publication Feb. 24, 1994; accepted in revised form June 10, 1994. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Anne B. Redfern, MD, 10 East 3lst Street, Baltimore, MD 21218.
T h e first group (n = 12) d e v e l o p e d u p p e r extremity n e u r o p a t h y immediately following fistula creation at either the brachial or antecubital level. Ten of these patients were w o m e n , and eight w e r e diabetic. T h e y ranged in age from 31 to 75 years with a mean age of 56 years. Eleven fistulas were brachial, and the r e m a i n i n g one was l o c a t e d in the a n t e c u b i t a l region. T h e second group (n = 10) presented with nonhealing wounds or impending or established u p p e r extremity tissue loss distal to an arteriovenous fistula. The m e a n age of this group was 55 years (range, 37-81 years). One half of these patients were w o m e n , and nine of the 10 were diabetic. Seven of the fistulas were brachial, one was a f o r e a r m fistula, and two w e r e radiocephalic fistulas at the wrist. The v a s c u l a r shunts had been established f r o m I month to 8 y e a r s at the t i m e o f o n s e t o f the p r e s e n t i n g problem.
Results Eleven patients had i m p a i r m e n t of m o r e than one m a j o r u p p e r e x t r e m i t y n e r v e ( T a b l e 1). In this group, no patient had evidence of impending tissue loss, N e r v e conduction studies were p e r f o r m e d in nine p a t i e n t s and c o n f i r m e d the o b v i o u s clinical findings in the involved extremities. Five patients u n d e r w e n t r e m o v a l or ligation o f the fistula within The Journal of Hand Surgery
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200
Redfern and Zimmerman / Complications of Vascular Access for Dialysis
Table 1. Clinical O u t c o m e of Patients With Ischemic N e u r o p a t h y Ipsilateral to an A r t e r i o v e n o u s Fistula for Hemodialysis (n = 12) Age "Years)
Sex
Diabetic
1
44
F
Y
Brachial
Ulnar, median, radial
Fistula ligated at 2 days postoperative
2
48
F
Y
Brachial
Median, radial
Fistula ligated 1 day postoperative
31
F
Y
Brachial
Ulnar, median, radial
Fistula ligated 2 months postoperative
4
70
F
Y
Antebrachial
Ulnar, median, radial
5
71
F
N
Brachial
Ulnar, median
6
75
F
N
Brachial
Median
7
60
M
N
Brachial
Ulnar, median
8
70
M
Y
Brachial
Ulnar, median, radial
9
52
F
Y
Brachial
Median, radial
Fistula ligated 6 months postoperative Fistula ligated at 1 month postoperative Patch angioplasty of brachial artery stenosis proximal to fistula at 3 months postoperative Brachial artery ligation and bypass distal to fistula at 1 month postoperative Fistula banded and then closed spontaneously at 2 months postoperatively Fistula retained
10
47
F
N
Brachial
Ulnar, median
Fistula retained
11 12
55 52
F F
Y Y
Brachial Brachial
Ulnar, median Ulnar, median
Fistula retained Fistula retained and closed spontaneously 3 months postop
Patient
Fistula Site
Neural Involvement
6 months of its creation. All of these patients had some degree of neural r e c o v e r y . T h r e e patients underwent surgical revision of the fistula in an attempt to i m p r o v e flow to the extremity distally. O f these, one patient had a p a t c h angioplasty to correct a brachial artery stenosis proximal to the fistula, with immediate p o s t o p e r a t i v e relief of a median neuropathy. To decrease the retrograde " s t e a l , " a second
Treatment
Outcome
Complete motor recovery at 7 months, complete sensory recovery at 20 months Complete motor recovery at 5 months, incomplete sensory recovery at time of death at 14 months Complete radial recovery, partial median and ulnar recovery at 4 months Partial radial and median recovery, no ulnar recovery at 3 months Complete ulnar recovery, partial median recovery at 7 months Complete recovery immediately postoperative
Partial ulnar recovery, no median recovery at 2 months No recovery at 6 months after banding
Near complete radial recovery, partial median recovery at time of death at 24 months Complete median recovery, partial ulnar recovery at 1 month No recovery at 6 months Complete median recovery, partial ulnar recovery at 8 months
patient had ligation o f the brachial a r t e r y distal to the fistula with a short segment b y p a s s graft across the surgical ligation. Only partial n e r v e r e c o v e r y resuited. In the third patient, the fistula w a s b a n d e d to decrease flow. The fistula closed s p o n t a n e o u s l y 2 months later, but no neural r e c o v e r y w a s n o t e d at 6 months following the banding. In four of the 12 patients, the fistula w a s retained
The Journal of Hand Surgery / Vol. 20A No. 2 March 1995
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12 Patients with Ischemic Neuropathy
I [
I
Re,re., 0, i
I
I
I
I
1 Unchanged 2 Improved With
Retained Patent Fistula
1 Unchanged With I
1 Improved With Spontaneous
Fistula Closure
Figure 1. Clinical outcome of patients with ischemic neuropathy ipsilateral to an arteriovenous fistula for hemodialysis. unmodified and used for dialysis. Two patients experienced partial spontaneous neural recovery while the fistula remained patent. The first patient evidenced nearly complete recovery of radial nerve function and partial median nerve r e c o v e r y 24 months following fistula creation. The second patient had complete median and partial ulnar recovery at 1 month after fistula creation. The third patient showed no improvement at 6 months with a retained patent fistula. In the final patient, the fistula closed spontaneously at 3 months after placement, with complete median and partial ulnar recovery 8 months following placement (Fig. 1). Case 1 A 44-year-old diabetic woman underwent construction of a left brachial arteriovenous fistula. Immediately after surgery, she felt tingling in her left hand. The following day, she developed weakness and hypesthesia in the hand. Sensibility was decreased in the ulnar sensory distribution and absent in the median and radial sensory distributions. A strong radial a r t e r y p u l s e was p r e s e n t . M o t o r strength was diminished in the posterior interosseous, median, and ulnar innervated muscle groups. The fistula was removed on the second postoperative day. Renal failure was treated with peritoneal dialysis followed by renal transplantation. Two weeks after removal of the fistula, there was normal ulnar nerve function and increased median motor function; posterior interosseous motor function, as well as median and radial nerve sensibility, was absent. Four months after fistula removal, radial nerve function was normal, and after 20 months, left upper extremity motor and sensory function was clinically normal.
Ten patients had established or impending tissue loss or nonhealing wounds distal to an arteriovenous fistula (Table 2). Noninvasive Doppler ultrasound studies and pneumoplethysmography were obtained in eight patients in this group. These demonstrated poor to absent pulsatile flow in the fingers distal to the fistula. Arteriography was performed in four instances. In two cases, significant brachial artery stenosis was identified proximal to the site of arteriovenous communication. In one patient, complete occlusion of the brachial artery distal to fistula was found. One patient with a radiocephalic fistula at the wrist had concomitant ulnar artery occlusion at G u y o n ' s canal; this condition was s u s p e c t e d on noninvasive testing and confirmed with arteriography. Five patients had surgical closure of the fistula, and in all five patients, prompt wound healing occurred. Ulcers or nonhealing traumatic w o u n d s closed in four of these patients, and an index finger amputation healed rapidly in the fifth patient. Three patients underwent surgical modifications of their fistulas in an attempt to augment flow to the distal portion of the extremity. One patient underwent correction of a brachial artery stenosis proximal to the fistula, with resultant prompt healing of the fourth and fifth ray amputations. In another patient, the fistula was revised to reduce flow, leading to subsequent healing of a long finger amputation stump. The third patient in this group had a vein graft to bypass the fistula and augment distal flow. The graft failed, and digital amputations at the metacarpophalangeal level failed to heal. Ultimately, a below-elbow amputation was required. The fistula was retained in the two final patients in this group. In one patient, a small finger amputation stump healed distal to a patent radiocephalic fistula.
202
Redfern and Zimmerman / Complications of Vascular Access for Dialysis
Table 2. Clinical Outcome of Patients With Tissue Ischemia or Nonhealing Wounds Distal to an Arteriovenous Fistula for Hemodialysis (n = 10) Patient
Age (Years)
Sex
Diabetic
Fistula Site
13
45
M
N
Wrist
Nonhealing traumatic wound
14
68
F
Y
Wrist
15
81
F
Y
Brachial
16
73
F
Y
Brachial
17
44
F
Y
Brachial
18
64
M
Y
Brachial
Ischemic ulcer thumb Ischemic necrosis index finger Ischemic ulcers thumb, small fingers Nonhealing traumatic wounds Ischemic necrosis ring, small fingers
19
57
M
Y
Brachial
20
71
M
Y
Brachial
21
40
M
Y
Forearm
22
37
F
Y
Brachial
Presentation
Nonhealing traumatic wound long finger Ischemic necrosis thumb, long finger Nonhealing traumatic wound proximal interphalangeal joint small finger Ischemic necrosis small finger
In the final patient, the fistula closed spontaneously and was followed by the prolonged healing of fourth and fifth ray amputations (Fig. 2).
Case 2 A 45-year-old nondiabetic man had a laceration o v e r the dorsum of the fight long finger metacarpophalangeal joint that failed to heal for 1 year despite operative d e b r i d e m e n t . Nine years b e f o r e the inj u r y , he began hemodialysis for h y p e r t e n s i v e nephropathy using a right radiocephalic arteriovenous fistula. After 3 years, he underwent successful renal t r a n s p l a n t a t i o n . T h e fistula r e m a i n e d patent. To
Treatment
Fistula closed surgically, radial artery vein graft reconstruction Fistula closed surgically Fistula closed surgically Fistula closed surgically
Outcome
Prompt healing
Prompt healing Healed amputation index finger Prompt reversal of ischemic changes
Fistula closed surgically
Healed ulcers
Correction brachial artery stenosis proximal to fistula Fistula revised to reduce flow
Healed amputation ring, small rays
Fistula revised with bypass graft, which subsequently closed Fistula retained
Fistula closed spontaneously
Healed amputation long finger Below-elbow amputation
Healed amputation small finger
Prolonged healing small and ring finger ray amputations
evaluate the reason for the failure of the w o u n d to heal, noninvasive studies were performed, and they demonstrated v e r y p o o r digital flow. An arteriogram confirmed ulnar artery occlusion with a radial artery steal (Fig. 3). The fistula was r e m o v e d with restoration of antegrade radial flow. Digital perfusion was restored, followed by prompt healing o f the long finger wound.
Discussion The presence of an arteriovenous communication in the extremity causes a pressure drop in the artery distal to the fistula that can be reconstituted to a
The Journal of Hand Surgery / Vol. 20A No. 2 March 1995
203
10 Patients with Tissue Ischemia orl Non Healing ...... W~
f
I Revision or I Ligation of Fistula: 8 Patients
i
[
I
No Surgical Modification of F stu a: 2 Pat ents
I
I Digital or Metacarpal Amputations
1 Non-Healing Wound, Required Below Elbow Amputation
1 Healed Digital Amputation
I 1 Healed After Spontaneous Closure
Fistula
Figure 2. Clinical outcome of patients with tissue ischemia or nonhealing wounds distal to an arteriovenous fistula for hemodialysis. variable degree by collateral or parallel arterial circuits. If the distal arterial pressure decrease is great enough, the pressure gradient for antegrade flow may cease altogether and arterial flow may actually reverse through the artery distal to the fistula. Strandness and Sumner pointed out that a " s t e a l "
Figure 3. Case 2. Arteriogram demonstrates patent radiocephalic arteriovenous fistula with ulnar artery occlusion.
is to some degree present in most fistulas. The propensity to develop a clinically significant steal relates to the quality of the collateral arteries that bypass the fistula and the presence of concomitant obs t r u c t i o n in t h e d i s t a l v a s c u l a t u r e . B r a c h i a l arteriovenous fistulas constitute a single artery system that relies on collateral vessels about the elbow to augment distal arterial flow; they are plagued with a high incidence of ischemic complications. In contrast, radial a r t e r y - c e p h a l i c vein fistulas are less likely to cause distal ischemic problems as long as the ulnar artery is patent and the superficial palmar arch is complete. 2 Wilbourn et al. in 1983 described a group of patients who developed multiple mononeuropathies of the distal limb, which they termed "ischemic monomelic neuropathy" (IMN). 3 The authors felt that the common etiologic factor in IMN was a sudden decrease in arterial blood flow caused by acute noncompressive occlusion of a major proximal limb artery or the shunting of arterial blood away from the distal extremity such as follows the construction of an arteriovenous fistula. The acute limb ischemia is severe enough to damage distal nerve fibers and p r o d u c e s y m p t o m s a b r u p t l y , but is too b r i e f or otherwise insufficient to cause muscle or skin necrosis. Riggs et al. point out that this complication occurs predominantly, if not exclusively, in diabetic patients, particularly those with peripheral neuropathy and evidence of arteriosclerotic vascular disease. 4 Two thirds of our patients with IMN were diabetic. Not all cases of nerve dysfunction following fistula creation are the result of IMN. Reinstein et al. reported three cases of nerve compression following creation of a brachial artery-basilic vein fistula. 5 In
204 Redfern and Zimmerman / Complications of Vascular Access for Dialysis two patients, the median nerve was involved, and in the third, the radial nerve. The causes of compression were a hematoma, an abscess, and a venous aneurysm. These patients demonstrated involvement of a single nerve by a space-occupying lesion, whereas the great majority of patients with IMN have involvement of more than one major peripheral nerve. Many authors have reported carpal tunnel syndrome in patients on hemodialysis. 6-9 Elevated v e n o u s p r e s s u r e , a l t e r a t i o n s in local h e m o d y namics, and thickening of flexor synovium have all b e e n i m p l i c a t e d as the c a u s e o f m e d i a n n e r v e compression at the wrist in patients with arteriovenous fistulas, The greatest recovery in our group was seen in patients who had removal of the fistula as soon as possible after diagnosis. If there are no other options for vascular access, or if peritoneal dialysis is not possible, an attempt may be made to retain the fistula. One may band it to limit flow or ligate the artery distal to the origin of the fistula to prevent the steal and use a short segment bypass f r om the a rt ery proximal to the fistula to a point beyond the ligation. Our experience with this procedure has been both limited and disappointing. Electrophysiologic studies of the nerves and noninvasive vascular studies, as well as arteriography, may be helpful in making the diagnosis of IMN and identifying any correctable vascular lesions that may allow retention of the fistula while improving distal blood flow. Decreased tissue perfusion distal to a vascular fistula may lead to nonhealing wounds or ischemic necrosis. Diabetic patients are said to be especially prone to " s t e a l " phenomena, but distal ischemia may also occur in nondiabetic patients, particularly in association with occlusive arterial disease. 1o The reported incidence of amputation distal to a fistula is low. Corry et al. reported no amputations in 428 patients, 11 while Haimov et al. reported 4 amputations (1 finger, 3 hands) in 444 patients. 12 Six of our 22 patients underwent amputation, all but 1 at the finger or ray level, and 9 of 10 patients with tissue ischemia in our series were diabetic. Two thirds of them had concomitant lower extremity, coronary, or cerebrovascular disease. The management of patients with ischemia begins with establishing the diagnosis of vascular insufficiency. Noninvasive vascular studies are very help-
ful in assessing distal perfusion, and arteriography may identify correctable occlusive lesions. When there is no correctable lesion, consideration should be given to closure of the fistula. Treatment decisions in these complex, chronically ill patients must be individualized, and close cooperation between nephrologists and vascular and hand surgeons is essential.
References 1. Iglehart JK. Health policy report, the American health system, the end stage renal disease program. N Engl J Med 1993;328:366-71. 2. Strandness DE, Sumner DS. Arteriovenous fistula. In: Strandness DE, Sumner DS. Hemodynamics for surgeons. New York: Grune & Stratton, 1975:621. 3. Wilbourn AJ, Furlan AJ, Hulley W, Ruschhaupt W. Ischemic monomelic neuropathy. Neurology 1983;33: 447-51. 4. Riggs JE, Moss AH, Labosky DA, Liput JH, Morgan J J, Gutman L. Upper extremity ischemic monomelic neuropathy: a complication of vascular access procedures in uremic diabetic patients. Neurology 1989;39: 997-8. 5. Reinstein L, Reed WP, Sadler JH, Baugher WH. Peripheral nerve compression by brachial artery-basilic vein vascular access in long-term hemodialysis. Arch Phys Med Rehabil 1984;65:142-4. 6. Warren DJ, Otieno LS. Carpal tunnel syndrome in patients on intermittent haemodialysis. Postgrad Med J 1975;51:450-2. 7. Mancusi-Ungaro A, Corres JJ, DiSpaltro F. Median carpal tunnel syndrome following a vascular shunt procedure in the forearm: case report. Plast Reconstr Surg 1976;57:96-7. 8. Holtmann B, Anderson CB. Carpal tunnel syndrome following vascular shunts for hemodialysis. Arch Surg 1977;112:65-6. 9. Gilbert MS, Robinson A, Baez A, Gupta S, Glabman S, Haimov M. Carpal tunnel syndrome in patients who are receiving long-term renal hemodialysis. J Bone Joint Surg 1988;70A:1145-53. 10. Connolly JE, Brownell DA, Levine EF, McCart M. Complications of renal dialysis access procedures. Arch Surg 1984;119:1325-8. 11. Corry RJ, Patel NP, West JC. Surgical management of complications of vascular access for hemodialysis. Surg Gynecol Obstet 1980;151:49-54. 12. Haimov M, Baez A, NeffM, Slitkin R. Complications or arteriovenous fistulas for hemodialysis. Arch Surg 1975;110:708-12.
More than 200,000 people in the United States are currently under t r e a t m e n t for end-stage renal disease. In 1990, 120,000 of the patients were treated with hemodialysis via surgically created arteriovenous fistulas, ~ T h e h e m o d y n a m i c a l t e r a t i o n s o f a proximal arteriovenous fistula can cause neurologic or ischemic p r o b l e m s in the extremities of patients with renal failure. T h e s e c o m p l i c a t i o n s are e s p e cially prevalent in persons with diabetes, w h o frequently h a v e preexisting peripheral n e u r o p a t h y and/ or occlusive peripheral vascular disease.
Materials and Methods B e t w e e n 1985 and 1992, 22 patients were treated for neuropathic or ischemic p r o b l e m s in their u p p e r extremities following arteriovenous fistula creation for hemodialysis. T w o distinct clinical presentation were identified. From the Raymond M. Curtis Hand Center, The Union Memorial Hospital, and Johns Hopkins University School of Medicine, Baltimore, MD. Received for publication Feb. 24, 1994; accepted in revised form June 10, 1994. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Anne B. Redfern, MD, 10 East 3lst Street, Baltimore, MD 21218.
T h e first group (n = 12) d e v e l o p e d u p p e r extremity n e u r o p a t h y immediately following fistula creation at either the brachial or antecubital level. Ten of these patients were w o m e n , and eight w e r e diabetic. T h e y ranged in age from 31 to 75 years with a mean age of 56 years. Eleven fistulas were brachial, and the r e m a i n i n g one was l o c a t e d in the a n t e c u b i t a l region. T h e second group (n = 10) presented with nonhealing wounds or impending or established u p p e r extremity tissue loss distal to an arteriovenous fistula. The m e a n age of this group was 55 years (range, 37-81 years). One half of these patients were w o m e n , and nine of the 10 were diabetic. Seven of the fistulas were brachial, one was a f o r e a r m fistula, and two w e r e radiocephalic fistulas at the wrist. The v a s c u l a r shunts had been established f r o m I month to 8 y e a r s at the t i m e o f o n s e t o f the p r e s e n t i n g problem.
Results Eleven patients had i m p a i r m e n t of m o r e than one m a j o r u p p e r e x t r e m i t y n e r v e ( T a b l e 1). In this group, no patient had evidence of impending tissue loss, N e r v e conduction studies were p e r f o r m e d in nine p a t i e n t s and c o n f i r m e d the o b v i o u s clinical findings in the involved extremities. Five patients u n d e r w e n t r e m o v a l or ligation o f the fistula within The Journal of Hand Surgery
199
200
Redfern and Zimmerman / Complications of Vascular Access for Dialysis
Table 1. Clinical O u t c o m e of Patients With Ischemic N e u r o p a t h y Ipsilateral to an A r t e r i o v e n o u s Fistula for Hemodialysis (n = 12) Age "Years)
Sex
Diabetic
1
44
F
Y
Brachial
Ulnar, median, radial
Fistula ligated at 2 days postoperative
2
48
F
Y
Brachial
Median, radial
Fistula ligated 1 day postoperative
31
F
Y
Brachial
Ulnar, median, radial
Fistula ligated 2 months postoperative
4
70
F
Y
Antebrachial
Ulnar, median, radial
5
71
F
N
Brachial
Ulnar, median
6
75
F
N
Brachial
Median
7
60
M
N
Brachial
Ulnar, median
8
70
M
Y
Brachial
Ulnar, median, radial
9
52
F
Y
Brachial
Median, radial
Fistula ligated 6 months postoperative Fistula ligated at 1 month postoperative Patch angioplasty of brachial artery stenosis proximal to fistula at 3 months postoperative Brachial artery ligation and bypass distal to fistula at 1 month postoperative Fistula banded and then closed spontaneously at 2 months postoperatively Fistula retained
10
47
F
N
Brachial
Ulnar, median
Fistula retained
11 12
55 52
F F
Y Y
Brachial Brachial
Ulnar, median Ulnar, median
Fistula retained Fistula retained and closed spontaneously 3 months postop
Patient
Fistula Site
Neural Involvement
6 months of its creation. All of these patients had some degree of neural r e c o v e r y . T h r e e patients underwent surgical revision of the fistula in an attempt to i m p r o v e flow to the extremity distally. O f these, one patient had a p a t c h angioplasty to correct a brachial artery stenosis proximal to the fistula, with immediate p o s t o p e r a t i v e relief of a median neuropathy. To decrease the retrograde " s t e a l , " a second
Treatment
Outcome
Complete motor recovery at 7 months, complete sensory recovery at 20 months Complete motor recovery at 5 months, incomplete sensory recovery at time of death at 14 months Complete radial recovery, partial median and ulnar recovery at 4 months Partial radial and median recovery, no ulnar recovery at 3 months Complete ulnar recovery, partial median recovery at 7 months Complete recovery immediately postoperative
Partial ulnar recovery, no median recovery at 2 months No recovery at 6 months after banding
Near complete radial recovery, partial median recovery at time of death at 24 months Complete median recovery, partial ulnar recovery at 1 month No recovery at 6 months Complete median recovery, partial ulnar recovery at 8 months
patient had ligation o f the brachial a r t e r y distal to the fistula with a short segment b y p a s s graft across the surgical ligation. Only partial n e r v e r e c o v e r y resuited. In the third patient, the fistula w a s b a n d e d to decrease flow. The fistula closed s p o n t a n e o u s l y 2 months later, but no neural r e c o v e r y w a s n o t e d at 6 months following the banding. In four of the 12 patients, the fistula w a s retained
The Journal of Hand Surgery / Vol. 20A No. 2 March 1995
201
12 Patients with Ischemic Neuropathy
I [
I
Re,re., 0, i
I
I
I
I
1 Unchanged 2 Improved With
Retained Patent Fistula
1 Unchanged With I
1 Improved With Spontaneous
Fistula Closure
Figure 1. Clinical outcome of patients with ischemic neuropathy ipsilateral to an arteriovenous fistula for hemodialysis. unmodified and used for dialysis. Two patients experienced partial spontaneous neural recovery while the fistula remained patent. The first patient evidenced nearly complete recovery of radial nerve function and partial median nerve r e c o v e r y 24 months following fistula creation. The second patient had complete median and partial ulnar recovery at 1 month after fistula creation. The third patient showed no improvement at 6 months with a retained patent fistula. In the final patient, the fistula closed spontaneously at 3 months after placement, with complete median and partial ulnar recovery 8 months following placement (Fig. 1). Case 1 A 44-year-old diabetic woman underwent construction of a left brachial arteriovenous fistula. Immediately after surgery, she felt tingling in her left hand. The following day, she developed weakness and hypesthesia in the hand. Sensibility was decreased in the ulnar sensory distribution and absent in the median and radial sensory distributions. A strong radial a r t e r y p u l s e was p r e s e n t . M o t o r strength was diminished in the posterior interosseous, median, and ulnar innervated muscle groups. The fistula was removed on the second postoperative day. Renal failure was treated with peritoneal dialysis followed by renal transplantation. Two weeks after removal of the fistula, there was normal ulnar nerve function and increased median motor function; posterior interosseous motor function, as well as median and radial nerve sensibility, was absent. Four months after fistula removal, radial nerve function was normal, and after 20 months, left upper extremity motor and sensory function was clinically normal.
Ten patients had established or impending tissue loss or nonhealing wounds distal to an arteriovenous fistula (Table 2). Noninvasive Doppler ultrasound studies and pneumoplethysmography were obtained in eight patients in this group. These demonstrated poor to absent pulsatile flow in the fingers distal to the fistula. Arteriography was performed in four instances. In two cases, significant brachial artery stenosis was identified proximal to the site of arteriovenous communication. In one patient, complete occlusion of the brachial artery distal to fistula was found. One patient with a radiocephalic fistula at the wrist had concomitant ulnar artery occlusion at G u y o n ' s canal; this condition was s u s p e c t e d on noninvasive testing and confirmed with arteriography. Five patients had surgical closure of the fistula, and in all five patients, prompt wound healing occurred. Ulcers or nonhealing traumatic w o u n d s closed in four of these patients, and an index finger amputation healed rapidly in the fifth patient. Three patients underwent surgical modifications of their fistulas in an attempt to augment flow to the distal portion of the extremity. One patient underwent correction of a brachial artery stenosis proximal to the fistula, with resultant prompt healing of the fourth and fifth ray amputations. In another patient, the fistula was revised to reduce flow, leading to subsequent healing of a long finger amputation stump. The third patient in this group had a vein graft to bypass the fistula and augment distal flow. The graft failed, and digital amputations at the metacarpophalangeal level failed to heal. Ultimately, a below-elbow amputation was required. The fistula was retained in the two final patients in this group. In one patient, a small finger amputation stump healed distal to a patent radiocephalic fistula.
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Table 2. Clinical Outcome of Patients With Tissue Ischemia or Nonhealing Wounds Distal to an Arteriovenous Fistula for Hemodialysis (n = 10) Patient
Age (Years)
Sex
Diabetic
Fistula Site
13
45
M
N
Wrist
Nonhealing traumatic wound
14
68
F
Y
Wrist
15
81
F
Y
Brachial
16
73
F
Y
Brachial
17
44
F
Y
Brachial
18
64
M
Y
Brachial
Ischemic ulcer thumb Ischemic necrosis index finger Ischemic ulcers thumb, small fingers Nonhealing traumatic wounds Ischemic necrosis ring, small fingers
19
57
M
Y
Brachial
20
71
M
Y
Brachial
21
40
M
Y
Forearm
22
37
F
Y
Brachial
Presentation
Nonhealing traumatic wound long finger Ischemic necrosis thumb, long finger Nonhealing traumatic wound proximal interphalangeal joint small finger Ischemic necrosis small finger
In the final patient, the fistula closed spontaneously and was followed by the prolonged healing of fourth and fifth ray amputations (Fig. 2).
Case 2 A 45-year-old nondiabetic man had a laceration o v e r the dorsum of the fight long finger metacarpophalangeal joint that failed to heal for 1 year despite operative d e b r i d e m e n t . Nine years b e f o r e the inj u r y , he began hemodialysis for h y p e r t e n s i v e nephropathy using a right radiocephalic arteriovenous fistula. After 3 years, he underwent successful renal t r a n s p l a n t a t i o n . T h e fistula r e m a i n e d patent. To
Treatment
Fistula closed surgically, radial artery vein graft reconstruction Fistula closed surgically Fistula closed surgically Fistula closed surgically
Outcome
Prompt healing
Prompt healing Healed amputation index finger Prompt reversal of ischemic changes
Fistula closed surgically
Healed ulcers
Correction brachial artery stenosis proximal to fistula Fistula revised to reduce flow
Healed amputation ring, small rays
Fistula revised with bypass graft, which subsequently closed Fistula retained
Fistula closed spontaneously
Healed amputation long finger Below-elbow amputation
Healed amputation small finger
Prolonged healing small and ring finger ray amputations
evaluate the reason for the failure of the w o u n d to heal, noninvasive studies were performed, and they demonstrated v e r y p o o r digital flow. An arteriogram confirmed ulnar artery occlusion with a radial artery steal (Fig. 3). The fistula was r e m o v e d with restoration of antegrade radial flow. Digital perfusion was restored, followed by prompt healing o f the long finger wound.
Discussion The presence of an arteriovenous communication in the extremity causes a pressure drop in the artery distal to the fistula that can be reconstituted to a
The Journal of Hand Surgery / Vol. 20A No. 2 March 1995
203
10 Patients with Tissue Ischemia orl Non Healing ...... W~
f
I Revision or I Ligation of Fistula: 8 Patients
i
[
I
No Surgical Modification of F stu a: 2 Pat ents
I
I Digital or Metacarpal Amputations
1 Non-Healing Wound, Required Below Elbow Amputation
1 Healed Digital Amputation
I 1 Healed After Spontaneous Closure
Fistula
Figure 2. Clinical outcome of patients with tissue ischemia or nonhealing wounds distal to an arteriovenous fistula for hemodialysis. variable degree by collateral or parallel arterial circuits. If the distal arterial pressure decrease is great enough, the pressure gradient for antegrade flow may cease altogether and arterial flow may actually reverse through the artery distal to the fistula. Strandness and Sumner pointed out that a " s t e a l "
Figure 3. Case 2. Arteriogram demonstrates patent radiocephalic arteriovenous fistula with ulnar artery occlusion.
is to some degree present in most fistulas. The propensity to develop a clinically significant steal relates to the quality of the collateral arteries that bypass the fistula and the presence of concomitant obs t r u c t i o n in t h e d i s t a l v a s c u l a t u r e . B r a c h i a l arteriovenous fistulas constitute a single artery system that relies on collateral vessels about the elbow to augment distal arterial flow; they are plagued with a high incidence of ischemic complications. In contrast, radial a r t e r y - c e p h a l i c vein fistulas are less likely to cause distal ischemic problems as long as the ulnar artery is patent and the superficial palmar arch is complete. 2 Wilbourn et al. in 1983 described a group of patients who developed multiple mononeuropathies of the distal limb, which they termed "ischemic monomelic neuropathy" (IMN). 3 The authors felt that the common etiologic factor in IMN was a sudden decrease in arterial blood flow caused by acute noncompressive occlusion of a major proximal limb artery or the shunting of arterial blood away from the distal extremity such as follows the construction of an arteriovenous fistula. The acute limb ischemia is severe enough to damage distal nerve fibers and p r o d u c e s y m p t o m s a b r u p t l y , but is too b r i e f or otherwise insufficient to cause muscle or skin necrosis. Riggs et al. point out that this complication occurs predominantly, if not exclusively, in diabetic patients, particularly those with peripheral neuropathy and evidence of arteriosclerotic vascular disease. 4 Two thirds of our patients with IMN were diabetic. Not all cases of nerve dysfunction following fistula creation are the result of IMN. Reinstein et al. reported three cases of nerve compression following creation of a brachial artery-basilic vein fistula. 5 In
204 Redfern and Zimmerman / Complications of Vascular Access for Dialysis two patients, the median nerve was involved, and in the third, the radial nerve. The causes of compression were a hematoma, an abscess, and a venous aneurysm. These patients demonstrated involvement of a single nerve by a space-occupying lesion, whereas the great majority of patients with IMN have involvement of more than one major peripheral nerve. Many authors have reported carpal tunnel syndrome in patients on hemodialysis. 6-9 Elevated v e n o u s p r e s s u r e , a l t e r a t i o n s in local h e m o d y namics, and thickening of flexor synovium have all b e e n i m p l i c a t e d as the c a u s e o f m e d i a n n e r v e compression at the wrist in patients with arteriovenous fistulas, The greatest recovery in our group was seen in patients who had removal of the fistula as soon as possible after diagnosis. If there are no other options for vascular access, or if peritoneal dialysis is not possible, an attempt may be made to retain the fistula. One may band it to limit flow or ligate the artery distal to the origin of the fistula to prevent the steal and use a short segment bypass f r om the a rt ery proximal to the fistula to a point beyond the ligation. Our experience with this procedure has been both limited and disappointing. Electrophysiologic studies of the nerves and noninvasive vascular studies, as well as arteriography, may be helpful in making the diagnosis of IMN and identifying any correctable vascular lesions that may allow retention of the fistula while improving distal blood flow. Decreased tissue perfusion distal to a vascular fistula may lead to nonhealing wounds or ischemic necrosis. Diabetic patients are said to be especially prone to " s t e a l " phenomena, but distal ischemia may also occur in nondiabetic patients, particularly in association with occlusive arterial disease. 1o The reported incidence of amputation distal to a fistula is low. Corry et al. reported no amputations in 428 patients, 11 while Haimov et al. reported 4 amputations (1 finger, 3 hands) in 444 patients. 12 Six of our 22 patients underwent amputation, all but 1 at the finger or ray level, and 9 of 10 patients with tissue ischemia in our series were diabetic. Two thirds of them had concomitant lower extremity, coronary, or cerebrovascular disease. The management of patients with ischemia begins with establishing the diagnosis of vascular insufficiency. Noninvasive vascular studies are very help-
ful in assessing distal perfusion, and arteriography may identify correctable occlusive lesions. When there is no correctable lesion, consideration should be given to closure of the fistula. Treatment decisions in these complex, chronically ill patients must be individualized, and close cooperation between nephrologists and vascular and hand surgeons is essential.
References 1. Iglehart JK. Health policy report, the American health system, the end stage renal disease program. N Engl J Med 1993;328:366-71. 2. Strandness DE, Sumner DS. Arteriovenous fistula. In: Strandness DE, Sumner DS. Hemodynamics for surgeons. New York: Grune & Stratton, 1975:621. 3. Wilbourn AJ, Furlan AJ, Hulley W, Ruschhaupt W. Ischemic monomelic neuropathy. Neurology 1983;33: 447-51. 4. Riggs JE, Moss AH, Labosky DA, Liput JH, Morgan J J, Gutman L. Upper extremity ischemic monomelic neuropathy: a complication of vascular access procedures in uremic diabetic patients. Neurology 1989;39: 997-8. 5. Reinstein L, Reed WP, Sadler JH, Baugher WH. Peripheral nerve compression by brachial artery-basilic vein vascular access in long-term hemodialysis. Arch Phys Med Rehabil 1984;65:142-4. 6. Warren DJ, Otieno LS. Carpal tunnel syndrome in patients on intermittent haemodialysis. Postgrad Med J 1975;51:450-2. 7. Mancusi-Ungaro A, Corres JJ, DiSpaltro F. Median carpal tunnel syndrome following a vascular shunt procedure in the forearm: case report. Plast Reconstr Surg 1976;57:96-7. 8. Holtmann B, Anderson CB. Carpal tunnel syndrome following vascular shunts for hemodialysis. Arch Surg 1977;112:65-6. 9. Gilbert MS, Robinson A, Baez A, Gupta S, Glabman S, Haimov M. Carpal tunnel syndrome in patients who are receiving long-term renal hemodialysis. J Bone Joint Surg 1988;70A:1145-53. 10. Connolly JE, Brownell DA, Levine EF, McCart M. Complications of renal dialysis access procedures. Arch Surg 1984;119:1325-8. 11. Corry RJ, Patel NP, West JC. Surgical management of complications of vascular access for hemodialysis. Surg Gynecol Obstet 1980;151:49-54. 12. Haimov M, Baez A, NeffM, Slitkin R. Complications or arteriovenous fistulas for hemodialysis. Arch Surg 1975;110:708-12.