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Hand ischemia due to arterial steal syndrome is an infrequent but potentially serious complication of hemodialysis access procedures. Correction of symptomatic steal syndrome typically involves fistula ligation, arterial banding, or graft lengthening, each of which provides varying degrees of success. The purpose of this study is to evaluate experience in the treatment of dialysis-associated hand ischemia by distal artery ligation and revascularization. A retrospective review was performed on 14 patients over a 6-year period who developed hand ischemia following hemodialysis access construction and underwent distal artery ligation and revascularization. Patient demographic data, operative indications, risk factors, and treatment outcome were noted. There were 10 men and four women, with a mean age of 52 years (range 21 to 73). Hand ischemia occurred in nine patients with arteriovenous grafts and five patients with arteriovenous fistulas. Nine patients developed steal syndrome within 1 month following the hemodialysis access procedure. All 14 patients underwent a surgical procedure for hand ischemia, which included ligation of the artery distal to arteriovenous fistula and arterial bypass, (Abstract continued) with reverse saphenous vein grafts in 10 patients, reversed cephalic vein grafts in three patients, and polytetrafluoroethylene graft in one patient. One patient with severe digital gangrene also required amputation. There was no perioperative morbidity or mortality. Following operation, all showed immediate improvement of the affected hand and remained free of symptoms. The cumulative patency rates of the hemodialysis access following the corrective procedure at 1, 3, and 5 years were 85.7%, 64.2%, and 42.9%, respectively. All arterial bypasses remained patent during follow-up, which ranged from 1 month to 5 years (mean 35 months). Distal arterial ligation with revascularization is an effective and durable treatment for patients with arterial steal syndrome following hemodialysis access construction. This technique can be performed with minimal morbidity and maintains a continuous access for hemodialysis.

The letter by Hisato Takagi provides further interesting data on the role of endoluminal superficial femoral artery (SFA) interventions. Their analysis of the four randomized trials that are presently available in the literature confirms that percutaneous angioplasty alone remains the primary treatment for SFA disease, with stent placement being reserved for technical and procedurerelated complications. The recent data on drug-eluting stents, although suggesting a marginal benefit, have shown that changes in stent technology have not altered the balance between primary PTA and primary stenting. The analysis by Takagi et al is weakened by virtue of the fact that they were unable to categorize treated vessels by TransAtlantic Inter-Society Consensus (TASC) classification. This would significantly aid those pursuing SFA interventions. Our own data suggested that TASC A and B lesions performed satisfactorily to PTA, with secondary stenting as needed, and that C and D lesions do not perform as well as conventional bypass. We still pursue the belief that primary PTA for SFA disease remains the treatment of choice, with stents being used selectively.