Introduction. Dialysis associated steal syndrome (DASS) constitutes a serious risk for patients undergoing vascular access operations. We aim to assess the measured volume flow using ultrasound in patients with clinically suspected steal syndrome and determine differences in flow among types of arteriovenous (AV) access. Methods. Patients with permanent hemodialysis access with and without ischemic steal underwent duplex ultrasound (US) exams for the assessment of volume flow and quantitative evidence of hemodynamic steal. Volume flow was measured in the proximal feeding artery. Results. 118 patients underwent US of which 82 (69.5%) had clinical evidence of steal. Women were more likely to develop steal compared to men (chi-squared test ). Mean volume flow in patients with steal was 1542？mL/min compared to 1087？mL/min ( ) in patients without evidence of steal. A significant difference in flow volumes in patients with and without steal was only seen in patients with a brachial-cephalic upper arm AV fistula (AVF) ( ). When comparing different types of access with steal, brachial-cephalic upper arm AVFs had higher volume flows than the upper extremity AV graft (AVG) group ( ). Conclusion. In patients with DASS, women were more likely to develop steal syndrome. Significantly higher volume flows were seen with brachial-cephalic upper arm AVF in patients with steal compared to those without. A physiologic basis of this US finding may be present, which warrants further study into the dynamics of flow and its relationship to the underlying peripheral arterial pathology in the development of ischemic steal. 1. Introduction Creating and maintaining a functional hemodialysis access conduit is challenging. With an increasing number of patients needing hemodialysis per year, the demand for a durable access with minimum complications is also increasing. Among the postoperative complications, dialysis associated steal syndrome (DASS) is the most morbid, often resulting in significant neurologic injury or tissue loss. Clinical risk factors previously identified in patients at risk for development of DASS include age greater than 60 years, female gender, diabetes, previous limb procedures, and type of fistula constructed [1–5]. DASS is a relatively uncommon phenomenon, occurring in 1%–10% of cases [3]. There are no reliable methods of predicting its development, and management is challenging. Preservation of the existing access and relief of the ischemia are a priority in the treatment of DASS. Bussell and associates described DASS in patients with a radial-cephalic
References
[1]
C. L. Wixon, J. D. Hughes, and J. L. Mills, “Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access,” Journal of the American College of Surgeons, vol. 191, no. 3, pp. 301–310, 2000.
[2]
S. S. Berman, A. T. Gentile, M. H. Glickman et al., “Distal revascularization-interval ligation for limb salvage and maintenance of dialysis access in ischemic steal syndrome,” Journal of Vascular Surgery, vol. 26, no. 3, pp. 393–404, 1997.
[3]
J. Ballard, T. J. Bunt, and J. Malone, “Major complications of angioaccess surgery,” American Journal of Surgery, vol. 66, pp. 36–27, 1992.
[4]
H. Schanzer, M. Skladany, M. Haimov et al., “Treatment of angioaccess-induced ischemia by revascularization,” Journal of Vascular Surgery, vol. 16, no. 6, pp. 861–866, 1992.
[5]
C. Sessa, G. Riehl, P. Porcu et al., “Treatment of hand ischemia following angioaccess surgery using the distal revascularization interval-ligation technique with preservation of vascular access: description of an 18-case series,” Annals of Vascular Surgery, vol. 18, no. 6, pp. 685–694, 2004.
[6]
J. A. Bussell, J. A. Abbott, and R. C. Lim, “A radial steal syndrome with arteriovenous fistula for hemodialysis. Studies in seven patients,” Annals of Internal Medicine, vol. 75, no. 3, pp. 387–394, 1971.
[7]
P. Zamani, J. Kaufman, and S. Kinlay, “Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis,” Vascular Medicine, vol. 14, no. 4, pp. 371–376, 2009.
[8]
“KDOQI clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access,” American Journal of Kidney Diseases, vol. 48, supplement 1, pp. S1–S322, 2006.
[9]
A. Schanzer, L. L. Nguyen, C. D. Owens, and H. Schanzer, “Use of digital pressure measurements for the diagnosis of AV access-induced hand ischemia,” Vascular Medicine, vol. 11, no. 4, pp. 227–231, 2006.
[10]
P. K. Papasavas, T. Reifsnyder, T. J. Birdas, P. F. Caushaj, and S. Leers, “Prediction of arteriovenous access steal syndrome utilizing digital pressure measurements,” Vascular and Endovascular Surgery, vol. 37, no. 3, pp. 179–184, 2003.
[11]
M. R. Back, M. Maynard, A. Winkler, and D. F. Bandyk, “Expected flow parameters within hemodialysis access and selection for remedial intervention of nonmaturing conduits,” Vascular and Endovascular Surgery, vol. 42, no. 2, pp. 150–158, 2008.
[12]
F. Basseau, N. Grenier, H. Trillaud et al., “Volume flow measurement in hemodialysis shunts using time-domain correlation,” Journal of Ultrasound in Medicine, vol. 18, no. 3, pp. 177–183, 1999.
[13]
F. van Hoek, M. R. Scheltinga, I. Kouwenberg, K. E. M. Moret, C. H. Beerenhout, and J. H. M. Tordoir, “Steal in hemodialysis patients depends on type of vascular access,” European Journal of Vascular and Endovascular Surgery, vol. 32, no. 6, pp. 710–717, 2006.
[14]
L. Diehl, K. Johansen, and J. Watson, “Operative management of distal ischemia complicating upper extremity dialysis access,” American Journal of Surgery, vol. 186, no. 1, pp. 17–19, 2003.
[15]
B. P. Mwipatayi, T. Bowles, S. Balakrishnan, J. Callaghan, E. Haluszkiewicz, and K. Sieunarine, “Ischemic steal syndrome: a case series and review of current management,” Current Surgery, vol. 63, no. 2, pp. 130–135, 2006.
[16]
A. M. Miles, “Upper limb ischemia after vascular access surgery: differential diagnosis and management,” Seminars in Dialysis, vol. 13, no. 5, pp. 312–315, 2000.
[17]
R. Pietura, M. Janczarek, W. Zaluska et al., “Colour Doppler ultrasound assessment of well-functioning mature arteriovenous fistulas for haemodialysis access,” European Journal of Radiology, vol. 55, no. 1, pp. 113–119, 2005.
[18]
R. E. May, J. Himmelfarb, M. Yenicesu et al., “Predictive measures of vascular access thrombosis: a prospective study,” Kidney International, vol. 52, no. 6, pp. 1656–1662, 1997.
[19]
W. H. Bay, M. L. Henry, J. M. Lazarus, N. L. Lew, J. Ling, and E. G. Lowrie, “Predicting hemodialysis access failure with color flow doppler ultrasound,” American Journal of Nephrology, vol. 18, no. 4, pp. 296–304, 1998.
[20]
J. Malik, M. Slavikova, and J. Maskova, “Dialysis access-associated steal syndrome: the role of ultrasonography,” Journal of Nephrology, vol. 16, no. 6, pp. 903–907, 2003.
[21]
G. S. Tynan-Cuisinier and S. S. Berman, “Strategies for predicting and treating access induced ischemic steal syndrome,” European Journal of Vascular and Endovascular Surgery, vol. 32, no. 3, pp. 309–315, 2006.
[22]
J. H. M. Tordoir, R. Dammers, and F. M. van der Sande, “Upper extremity ischemia and hemodialysis vascular access,” European Journal of Vascular and Endovascular Surgery, vol. 27, no. 1, pp. 1–5, 2004.
[23]
E. Wijnen, X. H. Keuter, N. R. Planken et al., “The relation between vascular access flow and different types of vascular access with systemic hemodynamics in hemodialysis patients,” Artificial Organs, vol. 29, no. 12, pp. 960–964, 2005.
