Medicine:Vascular access steal syndrome

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Vascular access steal syndrome
SpecialtyNephrology

In nephrology, vascular access steal syndrome is a syndrome caused by ischemia (not enough blood flow) resulting from a vascular access device (such as an arteriovenous fistula or synthetic vascular graft–AV fistula) that was installed to provide access for the inflow and outflow of blood during hemodialysis.

Signs

  • Pallor
  • Diminished pulses (distal to the fistula)
  • Necrosis[1]
  • Decreased wrist-brachial index (ratio of blood pressure measured in the wrist and the blood pressure measured in the upper arm), especially if below 0.6[2]

Symptoms

  • Pain distal to the fistula.

Symptoms are graded by their severity:[3]

  • Grade 0: No symptoms of steal
  • Grade 1: Mild - cool extremity, improvement in hand pulse with access occlusion
  • Grade 2: Moderate - Ischemic symptoms during dialysis
  • Grade 3: Severe - Ischemic hand pain outside of dialysis; Ulcers or gangrene of the fingers

Diagnosis

  • History and physical exam - relief of symptoms with compression of the fistula on exam is highly suggestive of steal
  • Arteriography[4]
  • Duplex ultrasound

Treatment

The fistula flow can be restricted through banding, or modulated through surgical revision.

Revascularization techniques

Banding techniques

  • Narrowing suture[7]
  • Plication[8]
  • Minimally invasive MILLER banding[9]
  • Tapering[10]
  • Surgical banding[11]

If the above methods fail, the fistula is ligated, and a new fistula is created in a more proximal location in the same limb, or in the contralateral limb.

Incidence

DASS occurs in about 1% of AV fistulas and 2.7-8% of PTFE grafts.[12][13]

Terminology

Within the contexts of nephrology and dialysis, vascular access steal syndrome is also less precisely just called steal syndrome (for short), but in wider contexts that term is ambiguous because it can refer to other steal syndromes, such as subclavian steal syndrome or coronary steal syndrome.[citation needed]

See also

  • Terms for anatomical location

References

  1. ↑ "[Hand ischemia due to "steal syndrome" in vascular access for hemodialysis]". G Chir 18 (1–2): 27–30. 1997. PMID 9206477. 
  2. ↑ "Management of dialysis access-associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction". J Vasc Surg 30 (1): 193–5. 1999. doi:10.1016/S0741-5214(99)70192-8. PMID 10394170. 
  3. ↑ Harris, Linda. Heodialysis Access: Nonthrombotic complications (8 ed.). In: Rutherford's Vascular SUrgery. pp. 1141-1152. 
  4. ↑ "Arterial steal syndrome: a modest proposal for an old paradigm". Am J Kidney Dis 48 (1): 88–97. 2006. doi:10.1053/j.ajkd.2006.03.077. PMID 16797390. 
  5. ↑ "Proximalization of the arterial inflow: a new technique to treat access-related ischemia". J Vasc Surg 43 (6): 1216–21. 2006. doi:10.1016/j.jvs.2006.01.025. PMID 16765242. 
  6. ↑ "Revision using distal inflow: a novel approach to dialysis-associated steal syndrome". Ann Vasc Surg 19 (5): 625–8. 2005. doi:10.1007/s10016-005-5827-7. PMID 16052391. 
  7. ↑ J.C. West; D.J. Bertsch; S.L. Peterson; M.P. Gannon; G. Norkus; R.P. Latsha; Kelley SE. (1991). "Arterial insufficiency in hemodialysis access procedures: correction by "banding" technique". Transpl Proc 23 (2): 1838–40. PMID 2053173. 
  8. ↑ S.P. Rivers; L.A. Scher; F.J. Veith. (1992). "Correction of steal syndrome secondary to hemodialysis access fistulas: a simplified quantitative technique". Surgery 112 (3): 593–7. PMID 1519174. 
  9. ↑ "Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome". Kidney Int 70 (4): 765–70. 2006. doi:10.1038/sj.ki.5001554. PMID 16816841. 
  10. ↑ Kirkman RL. (1991). "Technique for flow reduction in dialysis access fistulas". Surg Gyn Obstet 172 (3): 231–3. PMID 1994500. 
  11. ↑ "Banding of arteriovenous dialysis fistulas to correct high-output cardiac failure". Surgery 78 (5): 552–4. 1975. PMID 1188596. 
  12. ↑ "Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure". J Surg Res 74 (1): 8–10. 1998. doi:10.1006/jsre.1997.5206. PMID 9536965. 
  13. ↑ "Steal syndrome complicating hemodialysis access procedures: can it be predicted?". Ann Vasc Surg 14 (2): 138–44. 2000. doi:10.1007/s100169910025. PMID 10742428. 



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