Dialysis access−associated steal syndromes

Comparison between transposed arteriovenous fistulas and arteriovenous graft for the hemodialysis patients: A meta-analysis and systematic review

It is challenging for a surgeon to determine the appropriate vascular access for hemodialysis patients whose cephalic vein is usually inaccessible. The purpose of the study is to compare the complications and patency rates between transposed arteriovenous fistulas (tAVF) and arteriovenous graft (AVG) for the hemodialysis patients. Studies were recruited from PubMed, Cochrane library, EMBASE, the web of science databases, and reviewing reference lists of related studies from the inception dates to September 2, 2021. Statistical analyses were conducted using the statistical tool Review Manager version5.3 (Cochrane Collaboration, London, UK). I2 > 50% was defined as a high degree of heterogeneity, and then a random-effects model was used. Otherwise, the fixed-effects model was used. Odds ratio with its 95% confidence interval (95% CI) was used. Thirty-three trials (26 retrospective studies, four randomized controlled trials, two prospective trials, and one controlled-comparative study) with 6430 enrolled participants were identified in our analysis. The results showed that tAVF was accompanied with lower thrombosis rate (103/1184 (8.69%) vs 257/1367 (18.80%); I2 = 45%; 95% CI, 0.34 (0.26, 0.45)) and infection rate (43/2031 (2.12%) vs 180/2147 (8.38%); I2 = 0%; 95% CI, 0.20 (0.14, 0.30)) than arteriovenous graft. The significantly better primary patency rates, secondary patency rates, and primary assisted patency rates during follow-up were found in tAVF. However, the failure rate and the prevalence of hematoma were significantly lower in AVG group. No evidence showed the rate of overall mortality, steal syndrome, and aneurysm reduced in tAVF. Our results showed that tAVF is a promising vascular access technique for hemodialysis patients whose cephalic vein is inaccessible. Our data showed that tAVF has less thrombosis, infection risk, and better patency rates when compared with AVG. However, more attentions need to be paid to transposed arteriovenous fistulas maturation and hematoma.

Temporal serum metabolomic and lipidomic analyses distinguish patients with access-related hand disability following arteriovenous fistula creation

For end-stage kidney disease (ESKD) patients, hemodialysis requires durable vascular access which is often surgically created using an arteriovenous fistula (AVF). However, some ESKD patients that undergo AVF placement develop access-related hand dysfunction (ARHD) through unknown mechanisms. In this study, we sought to determine if changes in the serum metabolome could distinguish ESKD patients that develop ARHD from those that have normal hand function following AVF creation. Forty-five ESKD patients that underwent first-time AVF creation were included in this study. Blood samples were obtained pre-operatively and 6-weeks post-operatively and metabolites were extracted and analyzed using nuclear magnetic resonance spectroscopy. Patients underwent thorough examination of hand function at both timepoints using the following assessments: grip strength manometry, dexterity, sensation, motor and sensory nerve conduction testing, hemodynamics, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Nineteen of the forty-five patients displayed overt weakness using grip strength manometry (P < 0.0001). Unfortunately, the serum metabolome was indistinguishable between patients with and without weakness following AVF surgery. However, a significant correlation was found between the change in tryptophan levels and the change in grip strength suggesting a possible role of tryptophan-derived uremic metabolites in post-AVF hand-associated weakness. Compared to grip strength, changes in dexterity and sensation were smaller than those observed in grip strength, however, post-operative decreases in phenylalanine, glycine, and alanine were unique to patients that developed signs of motor or sensory disability following AVF creation.

N-acetylcysteine treatment attenuates hemodialysis access-related limb pathophysiology in mice with chronic kidney disease

The objective of the present study was to determine if treatment with N-acetylcysteine (NAC) could reduce access-related limb dysfunction in mice. Male and female C57BL6J mice were fed an adenine-supplemented diet to induce chronic kidney disease (CKD) prior to the surgical creation of an arteriovenous fistula (AVF) in the iliac vascular bundle. AVF creation significantly increased peak aortic and infrarenal vena cava blood flow velocities, but NAC treatment had no significant impact, indicating that fistula maturation was not impacted by NAC treatment. Hindlimb muscle and paw perfusion recovery and muscle capillary density in the AVF limb were unaffected by NAC treatment. However, NAC treatment significantly increased the mass of the tibialis anterior (P = 0.0120) and soleus (P = 0.0452) muscles post-AVF. There was a significant main effect of NAC treatment on hindlimb grip strength at postoperative day 12 (POD 12) (P = 0.0003), driven by significantly higher grip strength in both male (P = 0.0273) and female (P = 0.0031) mice treated with NAC. There was also a significant main effect of NAC treatment on the walking speed at postoperative day 12 (P = 0.0447), and post hoc testing revealed an improvement in NAC-treated male mice (P = 0.0091). The area of postsynaptic acetylcholine receptors (P = 0.0263) and motor endplates (P = 0.0240) was also increased by NAC treatment. Interestingly, hindlimb skeletal muscle mitochondrial oxidative phosphorylation trended higher in NAC-treated female mice but was not statistically significant (P = 0.0973). Muscle glutathione levels and redox status were not significantly impacted by NAC treatment in either sex. In summary, NAC treatment attenuated some aspects of neuromotor pathology in mice with chronic kidney disease following AVF creation.NEW & NOTEWORTHY Hemodialysis via autogenous arteriovenous fistula (AVF) is the preferred first-line modality for renal replacement therapy in patients with end-stage kidney disease. However, patients undergoing AVF surgery frequently experience a spectrum of hand disability symptoms postsurgery including weakness and neuromotor dysfunction. Unfortunately, no treatment is currently available to prevent or mitigate these symptoms. Here, we provide evidence that daily N-acetylcysteine supplementation can attenuate some aspects of limb neuromotor function in a preclinical mouse model of AVF.

An Expeditious and Precise Method for Diameter Reduction of Venous Aneurysm causing Arteriovenous Fistula Steal Syndrome

Clinically significant dialysis access steal syndrome occurs in 1% to 8% of patients. In the present report, we describe an innovative, hybrid option for venoplasty of a cephalic vein aneurysm using a vascular staple device in conjunction with a 6-mm, endovascular balloon placed a few centimeters distal to the brachial artery anastomosis in a 61-year-old man with stage 3 dialysis access steal syndrome secondary to overwhelming venous outflow. The patient experienced immediate postoperative symptom relief. The arteriovenous fistula was immediately accessible for dialysis, circumventing the need for a temporary dialysis catheter. The arteriovenous fistula was functional at 12 months of follow-up.

Recognizing dialysis access steal syndrome with central vein stenosis as arteriovenous fistula complication: A case report

INTRODUCTION

Ischemic consequences of hemodialysis arteriovenous (AV) access are infrequent, yet they can cause substantial limb impairment or even loss. Ischemia can be caused by many factors, but the most common etiology is reduced blood supply to the distal extremities due to blood flow through the AV fistula (AVF) or AV graft. We reported a case of dialysis access steal syndrome (DASS) in a diabetes mellitus patient.

CASE REPORT

A 69-year-old diabetic man with left brachiocephalic AVF on his left upper arm has main complaint of left-hand pain, swelling, and coldness. There are also trophic darkening changes in the distal first, third, and fourth fingers. A duplex doppler examination revealed a normal functional AV shunt with bidirectional distal retrograde inflow. There was also significant stenosis at axillary vein. So, a diagnosis of DASS with suspicion of distal anastomosis stenosis at axillary vein was made. The patient underwent digital amputation and surgical plication of the AV shunt. He also underwent percutaneous transluminal angioplasty at the level of axillary. After 10 days of care, he was later discharged.

CLINICAL DISCUSSION

DASS is life and limb-threatening clinical disorder. Not only does the discomfort make it difficult for the patient to tolerate hemodialysis, but the ischemia can cause tissue necrosis and the eventual loss of fingers and possibly the patient's life. Doppler ultrasonography is a non-invasive technique that provides important information about vascular anatomy and hemodynamics. Aggressive treatment, including limb surgery and intensive blood glucose regulation, will result in favourable results.

CONCLUSIONS

DASS is a rare condition usually encountered in hemodialysis patients with AVF. Proper diagnosis and management are needed to get an optimal outcome for the patient.

Risk Factors and Management of Hemodialysis Associated Distal Ischemia

OBJECTIVES

Hemodialysis-associated distal ischemia (HADI) is an uncommon, but significant complication after hemodialysis access creation that may require additional intervention. This study examines the risk factors for HADI and compares the outcomes of the different treatment modalities.

METHODS

The Vascular Quality Initiative hemodialysis access (2011-2019) registry was reviewed. Patients were classified based on the occurrence of HADI requiring intervention or not, and their respective characteristics were compared. Multivariable logistic regression was used to identify independent factors associated with HADI. Kaplan Meier curves of secondary patency after different modalities of surgical revision were compared.

RESULTS

There were 35,236 vascular access creations and 970 (2.75%) were complicated by HADI requiring intervention. Treatment was performed with access ligation in 224 patients (23%) and catheter-based techniques in 394 (41%). Open surgical revision consisted of banding in 127 (13%), distal revascularization interval ligation (DRIL) in 196 (20%), proximalization of arterial inflow (PAI) in 15 (1.5%), and revision using distal inflow (RUDI) in 14 (1.4%). Median time to HADI was 49 days (IQR 17-91 days). Multivariate regression demonstrated that white race, female sex, peripheral artery disease, coronary artery disease, diabetes, post-procedure antiplatelets, prosthetic grafts, upper arm access, and target vein diameter greater than 4 mm were significantly associated with increased risk for HADI. When compared to procedures without HADI, access patency was decreased when revision (excluding access ligation) was performed (secondary patency at 12 months, HADI revision vs none: 89.0% vs 92.4%, p<0.01). However, after multivariate Cox adjustment, revision for HADI was not independently significantly associated with access failure.

CONCLUSIONS

HADI complicates 2.75% of hemodialysis access cases and is more likely in white females with diabetes and arterial disease after upper arm prosthetic graft placement. The patency of dialysis access does not seem to be negatively impacted by the various methods of surgical revision for HADI.

Onychodystrophy as the Presenting Sign of Steal Syndrome

A man in his 70s presented to the dermatology nail clinic with a 1-month history of worsening onychodystrophy, leukonychia, and pain in his left fifth finger. Physical examination revealed a cool hand and absent radial pulse. Ischemia was suspected, and the patient was sent to the emergency department where the diagnosis of steal syndrome was made and his previously required arteriovenous fistula was ligated. This case highlights the clinical features of steal syndrome, that nail changes should be recognized as clinical features, and that urgent triage of these patients to vascular surgery is of critical importance.

Dialysis associated steal syndromes. A narrative review

BACKGROUND

To review contemporary concepts in the genesis of Dialysis Access Steal Syndrome (DASS) and its current management.

METHODS

An electronic search of literature from 1960 to 2020 in Pubmed and the Cochrane library was conducted and practice guidelines were examined. Search terms included dialysis, steal, ischemia, access and ESRD. Clinical presentation, pathophysiology, risk factors, diagnostic techniques and management outcomes of extremity ischemia following dialysis access creation were reviewed.

RESULTS

Symptomatic steal occurs in 4-10% of patietns after creation of hemodialysis access creation. Risk factos include brachial based fistula, diabetes, female sex, coronary heart disease, cerebrovascular disease, tobacco use, age more than 60 and hypertension. Diagnosis is mainly clinical and can be aided by non invasive testing. Correction o finflow stenosis, Distal revasulatisation with interval ligation, revision using distal inflow or other techniques are useful for fistula preservation.

CONCLUSIONS

Dialysis associated steal syndromes have a complex haemodynamic causation. Clinical presentation is diagnostic; however when the diagnosis is uncertain adjunctive noninvasive perfusion tests, duplex and other imaging amy be required. Management is guided by anatomic, patient and disease-related considerations.

Distal Revascularization and Interval Ligation for the Management of Dialysis Access Steal Syndrome

BACKGROUND

Treatment options for dialysis access steal syndrome (DASS) include distal revascularization with interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. This study examines the efficacy of DRIL in treating DASS and reports short-term bypass patency, access patency, and wound infection rates.

METHODS

A retrospective analysis was performed on adults diagnosed with DASS following hemo-dialysis access creation who underwent DRIL procedures between January 1, 2009 and May 11, 2017. Patients <18 years and those with lower extremity accesses or HeRO grafts that developed DASS were excluded. Data was obtained using electronic medical records and analyzed using SPSS software. Residual steal was defined as reintervention for DASS within 60 days of DRIL. Recurrent steal was defined as reintervention beyond 60 days.

RESULTS

Eighty-nine DRIL procedures were performed for correction of DASS. Population included 59.6% female (n = 53), 47.2% current/former smokers (n = 42), 76.4% diabetic (n = 68), and 79.8% AVF (n = 71). Symptom resolution was complete for 69.7% (n = 62), and partial for 25.8% (n = 23), with no improvement in 4.5% (n = 4). Following DRIL, mean DBI improved from 0.43 to 0.67 (P= 0.002). Mean steal classification improved from 3.04 to 0.64 (P< 0.001). Five patients required a subsequent procedure for DASS symptoms - 3 for residual steal and 2 for recurrent steal. Bypass patency at 6 months post DRIL was 93.3% (n = 83) primary, 97.8% (n = 87) primary-assisted, and 100% (n = 89) secondary patency. Access patency at 6 months post DRIL was 78.7% (n = 70) primary, 91% (n = 81) primary-assisted, and 94.4% (n = 84) secondary. Twenty-one patients (23.5%) had 24 cases of surgical site infections, with 70.8% (n = 17) occurring at the saphenectomy site. Wound infections re-solved within 60 days postoperatively in 23 out of 24 patients.

CONCLUSIONS

DRIL is highly effective in relieving symptoms of DASS and has excellent rates of short-term access and bypass patency. However, consideration must be given to the high wound infection rate and the potential need for subsequent procedures.

Blood flow distribution after end-to-side anastomosis with wide arteriotomy in extremity free flap surgery

PURPOSE

Although many studies have investigated the optimal anastomotic procedure for the end-to-side (ETS) procedure with a free flap, no study has focused on the size of the arteriotomy. Some surgeons have recently described the effectiveness of ETS with wide arteriotomy, but the postoperative haemodynamics remains unclear for free flaps created using this technique. The aim of this study was to use ultrasonography to evaluate the postoperative blood flow distribution after ETS with a wide arteriotomy in extremity free flap surgery.

METHODS

We evaluated 20 free flaps in 18 consecutive patients who received an ultrasonographic examination after free flap surgery using the ETS technique with wide arteriotomy for arterial anastomosis. All flaps were examined after surgery and blood flow was calculated for the flap and recipient vessels.

RESULTS

All 20 flaps survived, but one flap developed asymptomatic arterial thrombosis and 19 flaps were analysed. For the ETS technique with wide arteriotomy, peripheral circulation was well preserved in all flaps. Comparison of flap types showed that blood flow was significantly higher in myocutaneous flaps than in fasciocutaneous flaps, but there was no significant difference according to the size of the arteriotomy.

CONCLUSIONS

Given the range of arteriotomy performed using the ETS with a wide arteriotomy technique, the blood flow volume in the flap depended on the type of flap but not on the size of the arteriotomy. A steal phenomenon related to the creation of a wide window in the receipt artery was not found in the analysed retrospective cohort.

Short-term manual compression of hemodialysis fistula leads to a rise in cerebral oxygenation

BACKGROUND

Decreased cerebral perfusion and oxygenation are common in hemodialysis patients. Magnitude of the arteriovenous fistula involvement in this phenomenon is not known. The aim of this study was to investigate the effect that a short-term arteriovenous fistula flow interruption has on cerebral oxygenation and to review and suggest possible explanations.

METHODS

In 19 patients, basic laboratory and clinical data were obtained and arteriovenous fistula flow volume was measured by ultrasonography. Baseline regional cerebral oxygen saturation (rSO₂) was measured by near-infrared spectroscopy. Manual pressure was then applied on the fistula, resulting in total blood flow interruption. After 1 min of manual compression, rSO₂ and blood pressure values were noted again. The compression-related change in rSO₂ was assessed, as well as its association with arteriovenous fistula flow volume, blood pressure, and other parameters.

RESULTS

Mean cerebral rSO₂ increased after arteriovenous fistula compression (from 53.6% ± 11.4% to 55.6% ± 10.8%; p = 0.000001; 95% confidence interval = 1.39-2.56). The rSO₂ increase was higher in patients with lower rSO₂ at baseline (r = -0.46; p = 0.045).

CONCLUSION

A significant rise in cerebral oxygenation was observed following the manual compression of arteriovenous fistula. Therefore, the arteriovenous fistula could have a role in impaired cerebral oxygenation in hemodialysis patients.

Use of a temporary shunt to preserve the patency of a hemodialysis graft while performing ipsilateral axillo-femoral bypass

Increased blood flow in the subclavian artery feeding a vascular access for hemodialysis can rarely induce steal phenomena in the vertebral and internal mammary artery leading to potentially life-threatening conditions. On the contrary, transient interruption of blood flow in the subclavian artery feeding a dialysis arteriovenous fistula can theoretically induce access thrombosis. Here, we describe a technical maneuver preserving continuous ipsilateral upper arm access flow when constructing a unilateral axillo-femoral polytetrafluoroethylene bypass operation for critical limb ischemia in a hemodialysis patient.