Hemodialysis-Related Steal Syndrome: Predictive Factors and Response to Treatment with the Distal Revascularization-Interval Ligation Procedure
Article Outline
Hand ischemia due to steal causes major disability in affected members of the hemodialysis population. Between February 2000 and March 2007, 24 patients aged 37-77 years were identified who developed hand ischemia distal to a hemodialysis access and required a distal revascularization-interval ligation (DRIL) procedure. Of the 24 patients, 22 (92%) were diabetic, 14 (58%) were women, 7 (29%) had prosthetic grafts, and 17 (71%) had fistulas, all originating from the brachial artery. Duration between the initial dialysis access and the DRIL procedures ranged 12 hours to 10 months. Conduits used were saphenous vein in 13 (54%) cases, cephalic vein in 3 (12%) cases, basilic vein in 5 (21%) cases, and prosthetic grafts in 3 (12%) cases. There were no operative deaths. Improved blood flow and relief of symptoms were observed in 23 (96%) patients. The procedure failed early in one patient who had thrombosis of a prosthetic graft. Two patients required digital amputations. At a median follow-up of 50 months, 14 (58%) patients died using the access requiring the DRIL, 2 (8%) did not require dialysis, 3 (12%) were using a new access, and 5 (21%) were still using the access that had required the DRIL. In late follow-up, only one DRIL bypass required revision and the remainder were patent. One patient developed an ischemic hand 5 years after his DRIL procedure despite a patent bypass. The development of ischemic steal requiring performance of a DRIL procedure is most likely to occur in diabetic patients with dialysis access originating from the brachial artery. The procedure is effective in ameliorating symptoms while preserving the vascular access. The high long-term mortality rate observed in this series underscores the fact that patients requiring a DRIL procedure represent a subset of dialysis patients with advanced diabetic vascular disease and a limited life expectancy. Despite the effectiveness of the DRIL procedure, efforts should be concentrated on prevention of ischemic steal in order to lessen the morbidity and expense of this condition in the dialysis population.
Introduction
As the number of patients requiring hemodialysis continues to expand in the United States, there is a continuing demand for durable dialysis access and surgeons committed to maintenance of access with a minimum of complications. During the past decade increasing numbers of elderly and diabetic patients have joined the ranks of those receiving hemodialysis. These patients present a number of obstacles to the successful establishment and maintenance of dialysis access. Among the most morbid of these conditions is hand ischemia, or ischemic steal syndrome (ISS), often resulting in significant neurologic injury or tissue loss. Clinical risk factors previously identified in patients at risk for development of ISS include age greater than 60 years, female gender, diabetes, previous limb procedures, and type of fistula constructed.1, 2, 3, 4, 5 In some hemodialysis populations, these factors may be prevalent in the majority of patients. ISS is a relatively uncommon phenomenon, occurring in 1-10% of cases;3 there are no reliable methods of predicting its development, and management has proven to be challenging. The goal in treatment of these patients is preservation of the existing access and relief of the ischemia. While the traditional method of fistula ligation is effective at relieving ischemia, it results in loss of the access. Attempts to accomplish this goal via banding or dialysis graft lengthening procedures have been met with limited success.2, 6 First performed by Schanzer et al.6 in 1988, distal revascularization with interval ligation (DRIL) is now considered the most effective strategy1, 2, 5, 7 and has achieved the most consistent results in alleviating ischemia while maintaining access patency. We had observed an increasing frequency of this complication and a corresponding necessity for DRIL procedures in our practice. Accordingly, we elected to evaluate our dialysis population to identify factors predictive of the development of ISS and to assess the effectiveness of the DRIL procedure in treating this condition in our institution.
Patients and Methods
Between February 2000 and March 2007, 24 patients were identified at our institution that developed hand ischemia distal to a hemodialysis access that was severe enough to require a DRIL procedure. During the course of this study, seven patients underwent ligation and abandonment of their vascular access that was producing the ISS. The decision to abandon the access rather than perform a DRIL procedure was made by the attending surgeon in conjunction with the patient on the basis of life expectancy and alternative dialysis options. These patients were not included in this study. A retrospective chart review of the 24 patients who underwent a DRIL procedure was undertaken to identify demographic features, medical comorbidities, history of their vascular access, and anatomic factors that might be significant in the development of ischemia. Patient charts and dialysis unit records were reviewed to assess the patient's clinical status and identify the current dialysis access to evaluate long-term results.
The diagnosis and decision to perform the DRIL procedure were made at the discretion of the attending surgeon based primarily on the clinical history and physical examination. Contrast arteriography, vascular laboratory evaluation, and magnetic resonance angiography (MRA) were performed in many patients prior to performance of the procedure; but there was not a uniform protocol.
The DRIL technique followed the guidelines originally proposed by Schanzer et al.6 It involved the creation of a bypass graft originating from the native artery >5 cm proximal to the fistula anastomosis. This distance allowed for avoidance of the “pressure sink” described by Wixon et al.1 The artery was then ligated just distal to the fistula but proximal to the distal anastomosis of the bypass graft.
The response to treatment was determined by assessing whether the patient had relief of symptoms of ischemia as well as any need for digital amputation. The long-term response was evaluated by clinical patency of the bypass graft and maintenance of the original dialysis access. Patient records were evaluated for long-term mortality, need for subsequent access placement or revision, or tissue loss in the affected limb.
Results
Twenty-four patients underwent a DRIL procedure in our institution during the interval of this study. During that time there was an average of 330-380 patients on chronic hemodialysis at our facilities. Of that population, 42% were diabetic and 43% were women. Additionally, there were approximately 700 patients with chronic kidney disease stage 4 (CKD 4) and 120 patients classified as CKD 5 being cared for and prepared for dialysis. Over 1,700 primary and redo procedures for hemodialysis access were performed on our vascular surgery service during the time of this review. The arterial anastomosis originated on the brachial artery near the elbow in about 40% of cases. Although we do not have precise data on the incidence of ISS of all severities in our institution, the incidence of significant ISS is approximately 2% (5 in 250 cases annually).
The patients ranged in age from 37 to 77 years (mean 60.9). Of the 24 patients, 22 (92%) were diabetic, 21 (88%) had hypertension, 18 (75%) had hyperlipidemia, 14 (58%) were women, 11 (45%) had coronary artery disease, and 3 (12%) had a smoking history (Table I). Seven of 24 patients (29%) had prosthetic grafts and 17 (71%) had autogenous fistulas as their dialysis access (Table II).
Table I. Demographics of patients who underwent the DRIL procedure
| Variable | n (%) |
|---|---|
| Mean age = 60.9 years | |
| Gender | |
 Male | 10 (42) |
| Female | 14 (58) |
| Diabetes | 22 (92) |
| Smoking | 3 (12) |
| Hypertension | 21 (88) |
| Hyperlipidemia | 18 (75) |
| Coronary artery disease | 11 (45) |
Table II. Original access procedure in patients who developed ISS
| Procedure | n (%) |
|---|---|
| AVF | 17 (71) |
| Brachiocephalic | 13 |
| BVT | 4 |
| AV grafts | 7 (29) |
| Brachial-axillary | 5 |
| Forearm loop | 2 |
At the time of creation of the dialysis access, the brachial artery was used as the site of the arterial anastomosis in all 24 patients. Thirteen patients had a brachiocephalic arteriovenous fistula (AVF), four had basilic vein transposition (BVT), five had arteriovenous (AV) grafts to the axillary vein, and two had forearm loop grafts (Table II).
The duration of time between onset of symptoms and the DRIL procedure ranged from 12 hours to 10 months. Acute symptoms of ischemia included paresthesia, pain, coldness, and hand weakness. Patients with more chronic presentations generally complained of pain and, in four cases, had digital ulcerations or digital gangrene. Eleven of the 24 patients (46%) underwent their DRIL procedure within 30 days of AV access placement, while 13 (54%) underwent it after 30 days.
The conduit used for the DRIL procedure was the saphenous vein in 13 (54%) cases, cephalic vein in 3 (12%) cases, basilic vein in 5 (21%) cases, and prosthetic grafts in 3 (12%) cases (Table III). The proximal anastomosis was placed on the brachial artery in all cases, while the distal brachial artery was the site of the distal anastomosis in 20 limbs, the radial artery in two patients, and the ulnar artery in two patients.
Table III. Conduit used for revascularization
| Conduit | n (%) |
|---|---|
| Autogenous | 21 (88) |
| GSV | 13 |
| Basilic vein | 5 |
| Cephalic | 3 |
| Prosthetic | 3 (12) |
| PTFE | 3 |
There were no operative deaths and no major wound complications. Twenty-three of 24 patients (96%) had clinically improved blood flow to their hands and significant relief of symptoms. The procedure failed in one patient because of thrombosis of a prosthetic graft used in the DRIL. This occurred immediately after its placement and required removal and patch repair of the native artery with ligation of the AVF. Several patients who were experiencing paresthesia and weakness preoperatively had slow or incomplete resolution of their neuropathic symptoms postoperatively.
The overall limb salvage rate was excellent as no patient required arm or hand amputation. Two patients presenting with digital gangrene, of a third and a fifth digit, respectively, underwent digital amputations after adequate demarcation and healed. The two patients presenting with ischemic ulcers also went on to complete healing (Table IV).
Table IV. Short- and long-term follow-up of DRIL procedures
| n (%) | |
|---|---|
| Median follow-up = 50 months | |
| Intraoperative deaths | 0 |
| Maintenance of access | 21 (87) |
| Patency of bypass grafts | 23 (95) |
| Perioperative mortality (<30 days) | 0 |
| Long-term mortality (>30 days) | 14 (58) |
| Amputations | |
| Limb/hand | 0 |
| Digits | 2 (8) |
| Wound healing | 2 (8) |
At a median follow-up period of 50 months, 14 (58%) patients died while continuing to use the access requiring the DRIL procedure. Five patients (21%) were alive and using the access that required the DRIL procedure, 2 (8%) no longer required dialysis, and 3 (12%) were using a new access. One DRIL procedure required operative revision for vein graft stenosis. A second patient developed an ischemic hand 5 years after his bypass procedure despite a patent bypass and was found to have progressive occlusive disease distal to the DRIL. He underwent plication of his AVF with some improvement, and his fistula is still in use 6 years after the DRIL procedure.
Discussion
Complications of vascular access, including thrombosis, bleeding, infection, pseudoaneurysm, and distal ischemia,8, 9 are the largest cause of morbidity in the hemodialysis population in the United States.10 Although not the most common, among the most morbid of these conditions is hand ischemia, or steal syndrome, often resulting in significant neurologic injury or tissue loss. Management has proven to be a challenge to the surgeon because of the desire to maintain access while alleviating the ischemia in this difficult population with advanced peripheral vascular disease.
Approximately 80% of patients with a functional dialysis access are estimated to have a physiologic steal as demonstrated by reduction in distal perfusion pressure.11 However, clinically significant ISS is uncommon. Most reports have found that the majority of patients who develop ISS do so within the first 30 days following creation of a new access.2, 4 Schanzer et al.,6 in their 1988 review, reported that ISS occurs in approximately 1% of AVFs and 2.7-4.3% of AV grafts. Other authors have found an incidence as high as 10%.3 Obviously, patient populations and surgeon biases regarding anatomic configuration of vascular accesses will impact the incidence of this complication. In 2000, Wixon et al.1 published a detailed analysis on the hemodynamics of the AVF. They described the physiologic consequences on arterial blood flow in the limb caused by the relative resistances in the peripheral arterial system, the parallel AVF, as well as anatomic configurations of the access. They also provided a detailed explanation of how the DRIL procedure is effective at alleviating the ischemia.
Through several case series, preoperative risk factors for developing ISS have been identified and include age >60 years, female gender, diabetes, construction of an autogenous fistula, multiple previous operations on the limb, and use of the brachial artery as the donor vessel.1, 2, 3, 4, 5 The patients undergoing the DRIL procedure in our series corroborate almost all of these results, particularly with respect to the high incidence of diabetes and the universal use of brachial artery inflow.
A variety of methods to manage the patient with ISS have been used, including ligation, banding, and lengthening procedures. The latter procedures depend on increasing resistance to flow in the AV access but are often accompanied by thrombosis. Despite a reasonably large experience in banding procedures, there remains limited physiologic data to quantify the extent of banding that will consistently relieve the ischemia while preserving the access. Jain et al.12 used intraoperative angiodynography to determine the degree of banding and reported success in three patients, while DeCaprio et al.13 utilized digital photoplethysmography. Berman et al.2 reported a success rate of 52% with banding procedures but again found that access thrombosis was the most prevalent cause of failure. In certain cases, simple ligation of the fistula may be the treatment of choice, sacrificing the access in an attempt to salvage the limb and preserve function.
The DRIL procedure has produced the most consistent and excellent results in the management of patients with ISS. In 1992, Schanzer et al.4 described 14 patients with 1-year access patency of 81.7% and with all the bypass grafts remaining open. Berman et al.2 subsequently reported on 21 patients with limb salvage and graft patency of 100% and 94% at 18 months, respectively, by life-table analysis. Knox et al.11 reported a series of 55 patients, the largest to date, with 90% having substantial or complete resolution of ISS. The outcome of the DRIL procedures in the present series are consistent with these reports, with 96% graft patency as well as a 96% short-term success rate in relieving symptoms and salvaging limbs while preserving the vascular access.
Despite the success described with the DRIL procedure, there remains some reluctance on the part of surgeons to perform a bypass and ligate the brachial artery in order to preserve a vascular access that is known to have a limited life span. Additionally, conduit availability, presence of infection, and severe atherosclerosis may limit the surgeon's options. Accordingly, other alternatives continue to be described in the literature. Minion et al.14 described a novel technique, revision using distal inflow (RUDI), involving ligation of the fistula at its origin followed by reestablishment of the fistula via a bypass from a more distal arterial source to the venous limb. In a small series of four patients with 4-14 months of follow-up, three patients had complete resolution of symptoms, while the fourth experienced residual paresthesia. On the basis of a sophisticated physiologic analysis, Gradman and Pozrikidis15 described alternatives to the treatment of ISS, including distal revascularization without interval ligation and conversion of a prosthetic brachial-axillary access to an axillary-axillary loop access or an axillary-brachial access. The latter technique, like RUDI, increases distal flow by increasing the pressure at the point where flow is split between the distal arm and fistula. Interestingly, using this model, the DRIL procedure was most effective at increasing distal arterial blood flow.
In addition to treating instances of ISS when it follows the creation of a vascular access, knowledge of predisposing factors allows the surgeon to plan an operation that is less likely to result in the condition. Techniques to accomplish this include avoidance of the brachial artery at the elbow by using more proximal inflow sources, use of the proximal radial artery, limiting the size of the arterial anastomosis, and using long-term venous catheters in patients with multiple risk factors and limited life expectancy. Although beyond the scope of this report, we believe we have reduced the incidence of ISS in our patient population using these means.
The unique finding of the present series is the high mortality that was observed in this patient population, with 58% being dead at a median follow-up of 50 months. Previous series of patients undergoing the DRIL procedure have not reported long-term mortality. Diabetes is known to increase the relative risk of mortality in dialysis patients by about 40%,16 and since almost all of our patients were diabetic, this finding is not surprising. Overall mortality rates in the dialysis population at our institution are better than national norms. We believe the findings in this series are indicative of the fact that patients who require a DRIL procedure represent a subset of dialysis patients who have advanced diabetic vascular disease and therefore a limited life expectancy.
Conclusion
Development of ischemic steal after placement of a hemodialysis fistula or graft remains a cause of significant morbidity and is seen almost exclusively in diabetic patients with AV access that originates on the brachial artery near the elbow. While the DRIL procedure is effective at relieving the ischemia and preserving the vascular access, knowledge of predisposing clinical and anatomic factors should allow the surgeon to avoid the complication of ISS in most cases. The observation of limited life expectancy for these patients is unique to this series and is probably a consequence of advanced diabetic peripheral vascular disease. It is a factor that should be considered when managing the hemodialysis access of these patients.
References
- . Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access. J Am Coll Surg. 2000;191:301–310
- Distal revascularization-interval ligation for limb salvage and maintenance of dialysis access in ischemic steal syndrome. J Vasc Surg. 1997;26:393–404
- . Major complications of angioaccess surgery. Am J Surg. 1992;66:36-27
- . Treatment of angioaccess-induced ischemia by revascularization. J Vasc Surg. 1992;16:861–866
- 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. Ann Vasc Surg. 2004;18:685–694
- Treatment of ischemia due to “steal” by arteriovenous fistula with distal artery ligation and revascularization. J Vasc Surg. 1988;7:770–773
- . The treatment of hand ischemia by arterial ligation and upper extremity bypass after angioaccess surgery. J Am Coll Surg. 1996;183:239–242
- . Operative management of distal ischemia complicating upper extremity dialysis access. Am J Surg. 2003;186:17–19
- Ischemic steal syndrome: a case series and review of current management. J Curr Surg. 2006;63:130–135
- . Upper limb ischemia after vascular access surgery: differential diagnosis and management. Semin Dial. 2000;13:312–315
- Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access. J Vasc Surg. 2002;36:250–256
- . A new technique to correct vascular steal secondary to hemodialysis grafts. Surg Gynecol Obstet. 1993;175:183–184
- Steal syndrome complicating hemodialysis access. Cardiovasc Res. 1997;5:648–653
- . Revision using distal inflow: a novel approach to dialysis-associated steal syndrome. Ann Vasc Surg. 2005;19:625–628
- . Analysis of options for mitigating hemodialysis access-related ischemic steal phenomena. Ann Vasc Surg. 2004;18:59–65
- Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS). J Am Soc Nephrol. 2003;14:3270–3277
Presented at the 25th Annual Meeting of the Southern California Vascular Surgical Society, Coronado, CA, May 5, 2007.
PII: S0890-5096(08)00008-3
doi:10.1016/j.avsg.2007.12.005
© 2008 Annals of Vascular Surgery Inc. Published by Elsevier Inc All rights reserved.
