The American Journal of Surgery 186 (2003) 17–19
Scientific paper
Operative management of distal ischemia complicating upper extremity dialysis access Lance Diehl, M.D., Kaj Johansen, M.D., Ph.D., Jim Watson, M.D.* Vascular Institute of the Northwest, 1600 E Jefferson, No. 101, Seattle, WA 98122, USA Manuscript received January 13, 2003; revised manuscript March 3, 2003 Presented at the 89th Annual Meeting of the North Pacific Surgical Association, Seattle, Washington, November 8 –9, 2002
Abstract Background: Ischemia distal to a functioning arteriovenous dialysis access is an infrequent but potentially serious complication that can be difficult to manage while maintaining access patency. Methods: Retrospective review was made of all patients requiring operative intervention for dialysis access-induced distal ischemia from 1998 to 2002 in a tertiary vascular surgery referral practice. Results: Twelve patients had 13 hands with ischemic changes requiring intervention after placement of hemodialysis access. Ischemia was successfully treated in all cases by distal revascularization-interval ligation. Dialysis access patency was better than expected. Conclusions: Distal revascularization-interval ligation is the optimal management for dialysis access-induced ischemia and should be attempted whenever possible. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Dialysis access; Complications; Distal revascularization-interval ligation
Common complications of dialysis access procedures include early thrombosis, bleeding, infection, and—perhaps the most serious— distal ischemia. Ischemic complications of upper extremity dialysis access can be relatively benign, such as finger tingling during dialysis that resolves spontaneously with time, or may be devastating, such as distal gangrene leading to finger or hand amputation. Ischemia significant enough to require intervention after dialysis access placement is uncommon (1% to 8%) [1– 4] but can be difficult to manage. The simplest method to treat dialysis access induced ischemia is to ligate the arteriovenous (AV) graft or fistula. Assuming the artery has not been narrowed, this approach has the advantage of immediately restoring distal perfusion. An obvious disadvantage is the need to establish a new access, and unfortunately the current site is usually abandoned as unsuitable for future access placement. Others have proposed methods of “banding” the access— deliberately rendering it stenotic, usually by carefully placed sutures or an extrinsic “belt” that increases flow
* Corresponding author. Tel.: ⫹1-206-320-3100; fax: ⫹1-206-3203188 E-mail address:
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resistance and diminishes “steal” from the distal extremity [5–7]. Unfortunately such efforts frequently fail, either banding the access too loosely, resulting in persistent steal, or too tightly, resulting in access thrombosis. Distal revascularization-interval ligation (DRIL) is designed to reliably treat the distal ischemia while maintaining access patency [8]. Patients and methods Since 1998 we have treated 14 limbs in 13 patients with DRIL for dialysis access induced distal ischemia. There were 8 men and 5 women with an average age of 58 years (range 33 to 77). Ten patients had diabetes mellitus; the cause of renal failure in the other 3 patients was polycystic kidney disease, recurrent pyelonephritis, and Fabry’s disease in 1 patient each. All patients in this report exhibited arterial ischemia distal to a functioning ipsilateral dialysis access. Access characteristics included 3 synthetic forearm loop grafts, 4 upper arm cryopreserved vein grafts, 2 upper arm arteriovenous fistulae, 1 upper arm synthetic graft, 2 Bresciacimino arteriovenous fistulae, and 2 forearm cryopreserved
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00118-1
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L. Diehl et al. / The American Journal of Surgery 186 (2003) 17–19
vein grafts. Nine patients developed their ischemia after the first access placement and 5 patients developed steal after two or more access procedures in the affected limb. All patients experienced hand or forearm pain, or both, as a component of their steal syndrome and 4 of the 14 limbs had digital gangrene. Distal revascularization-interval ligation was performed according to the method of Schanzer [8]. The bypass is constructed from the inflow artery at least 5 cm above the arterial anastamosis of the dialysis access to a suitable point below the anastamosis. The artery is then ligated between the distal bypass anastamosis and the arterial anastamosis of the dialysis access. Reversed autogenous vein was used for DRIL conduit in 12 limbs and polytetrafluoroethylene in 1.
Results From 1998 to 2002, 14 limbs in 13 patients experiencing significant upper extremity ischemia distal to a functioning dialysis access underwent a DRIL procedure to restore adequate distal limb perfusion. One patient underwent ligation of a brachiocephalic arteriovenous fistula due to venous hypertension after a DRIL procedure resulted in significant improvement of his ischemic symptoms. The patient had a dialysis access established in the contralateral upper extremity that also resulted in hand ischemia and was then treated by a second DRIL procedure. One patient was referred after placement of access in the contralateral limb at an outside institution had resulted in finger necrosis and amputation. A new access was placed on the ipsilateral limb. He developed finger tingling during dialysis that was improving but he presented 3 months later with digit necrosis. One patient died within 24 hours after DRIL placement, likely due to a myocardial infarction. She died with a patent DRIL, a patent dialysis access, and complete relief of her hand pain. She was excluded from further statistical analysis, and our data thus are derived from records of 13 DRIL procedures in 12 patients. All patients had improvement of their ischemic symptoms after DRIL placement, based on both patient perception and clinical evaluation. Eight patients (57%) experienced complete resolution of their symptoms. The other 4 patients all had diabetes mellitus and digital gangrene. Three underwent successful amputation of the gangrenous portion of the digit. One patient with fingertip gangrene and significant associated pain refused amputation of the gangrenous tissue but became pain-free after DRIL. The cumulative patency of the access procedure causing the steal syndrome after the DRIL was 90% at 6 months, 78% at 12 months, and 71% at 24 months. Distal revascularization-interval ligation patency was 100% at 6 and 12 months, and 83% at 24 months. The overall mortality was 54%, with death occurring an average of 16.5 months after DRIL placement.
Comments Distal ischemia after dialysis access placement can cause pain or, occasionally, tissue necrosis. Pain in a previously normal hand can be quite distressing and digital necrosis can be devastating. Determining which patients are at risk of developing distal ischemia after dialysis access placement can be difficult. From a hemodynamic standpoint, any increase in the resistance to flow in the peripheral vascular bed supplied by the artery on which the access is based will promote the steal phenomenon. Diabetics often develop atherosclerotic stenoses of the forearm vessels as well as significant peripheral digital arteriopathies that both increase resistance in the distal vascular bed. Several authors have noted that diabetic patients seem to be at particular risk of developing clinically significant distal ischemia after dialysis access placement [1,7–12]. Ten of our 13 steal patients and all patients with digital gangrene had diabetes, confirming that these patients are at increased risk for clinically significant ischemia after angioaccess placement. A recent report from Yeager et al [12] highlights the fact that digital ischemia in this patient population is multifactorial and often occurs in the absence of a patent ipsilateral dialysis access. They concluded that “finger gangrene in patients with ESRD is primarily related to severe distal atherosclerosis and not ischemic steal syndrome.” We agree that distal atherosclerosis is necessary for ischemia and especially gangrene to occur. However, we believe that dialysis access placement with the obligate associated arterial steal is often the final insult that precipitates the ischemia and may result in gangrene. Few surgeons would propose failing to correct the steal associated with a functional dialysis access when faced with severe symptomatic distal ischemia. Three patients in our series healed their digit amputations after DRIL but still had significant hand pain. This highlights the fact that ischemia may not be the cause of all digital pain after placement of dialysis access. We note the freedom from repeat amputations after revascularization in our series. Repeat amputations are frequently required in the absence of revascularization [12]. Ligation is the simplest, most reliable method for treating dialysis access induced distal ischemia. A well-functioning dialysis access is lost, however. Use of the same site in the future can be difficult or impossible. The only 2 patients in our series with bilateral upper extremity digital gangrene both developed gangrene only after placement of their ipsilateral dialysis access. If the access is ligated to treat the ischemia, establishing a new access would appear to be at high risk for also causing digital gangrene. Narrowing of the dialysis access by suture plication or banding can effectively increase resistance through the access and increase perfusion to the ischemic distal tissue [13]. However, subsequent access thrombosis rates are unacceptably high [14,15], and most surgeons have abandoned dialysis access banding as a treatment option for distal ischemia. Distal revascularization-interval ligation is the only tech-
L. Diehl et al. / The American Journal of Surgery 186 (2003) 17–19
nique for treating dialysis access induced steal that reliably relieves distal ischemia and maintains access patency. All 13 patients we treated with the DRIL procedure had effective relief of their distal ischemia. Access patency was 71% at 24 months (respectable in view of the fact that 1-year cumulative patency for synthetic dialysis grafts would be expected to be less than 60%) [16,17]. Efficient flow through a dialysis access is prerequisite to the development of the steal phenomenon. Our data suggest that if the distal ischemia can be effectively treated without compromising access patency these accesses may have a better than average expected patency. Patients who suffer from significant distal ischemia after dialysis access placement represent a particularly high risk group with most patients exhibiting symptomatic coronary artery disease, peripheral vascular disease, and diabetes in addition to their renal failure. Survival after the onset of digital gangrene is only 27% at 2 years in these patients [11]. Our experience confirms the high mortality rate in these patients and DRIL would appear to be the optimal strategy to minimize interventions in this patient population. We conclude that for patients who suffer from clinically significant ischemia distal to a functional dialysis access, a DRIL procedure will safely, effectively, and durably treat the ischemia while maintaining dialysis access.
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