Arteriovenous access ischemic steal (AVAIS) in haemodialysis: a consensus from the Charing Cross Vascular Access Masterclass 2016

Abstract

Arteriovenous access ischaemic steal (AVAIS) is a serious and not infrequent complication of vascular access. Pathophysiology is key to diagnosis, investigation and management. Ischaemia distal to an AV access is due to multiple factors. Clinical steal is not simply blood diversion but pressure changes within the adapted vasculature with distal hypoperfusion and resultant poor perfusion pressures in the distal extremity. Reversal of flow within the artery distal to the AV access may be seen but this is not associated with ischaemia in most cases.Terminology is varied and it is suggested that arteriovenous access ischemic steal (AVAIS) is the preferred term. In all cases AVAIS should be carefully classified on clinical symptoms as these determine management options and allow standardisation for studies.Diabetes and peripheral arterial occlusive disease are risk factors but a 'high risk patient' profile is not clear and definitive vascular access should not be automatically avoided in these patient groups.Multiple treatment modalities have been described and their use should be directed by appropriate assessment, investigation and treatment of the underlying pathophysiology. Comparison of treatment options is difficult as published studies are heavily biased. Whilst no single technique is suitable for all cases of AVAIS there are some that suit particular scenarios and mild AVAIS may benefit from observation whilst more severe steal mandates surgical intervention.

Basilic vein transposition for unsuitable upper arm hemodialysis needle access segment may attenuate concurrent hand ischemia

“…A <50 mmHg finger pressure (Pdig) or a <0.6 digital brachial index (DBI) are accepted cut‐off points of hand ischemia . The degree of HAIDI was scored as advised in a recent consensus document (supplementary table 1) . Additional imaging using a Seldinger or MR‐angiography is indicated if patients suffered from a grade 2b, 3, or 4 HAIDI, unless an arterial stenosis is deemed highly unlikely as in very young HD‐patients.…”

Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous Fistula

“…Furthermore, the generally accepted 0.6 DBI ischaemic threshold was challenged in a recent consensus meeting proposing a threshold of 0.4. 22 Patients who refused surgery or who were considered unfit may have introduced selection bias, possibly leading to under or overestimation of outcome measures. Moreover, the upper measurement limit of the access flow equipment is 4 L/ min, precluding accurate determination in some patients possibly having higher access flows.…”

“…20 HAIDI was graded by analogy to the Fontaine classification as proposed in a recent consensus meeting. 21,22 In one hospital (MMC), patients completed a hand ischaemic questionnaire (HIQ). This questionnaire scores severity (0, none e 10, extreme) and frequency (0, never e 10, always) of the five cardinal symptoms of hand ischaemia on a visual analogue scale.…”

Distal radial artery ligation for treatment of steal syndrome associated with radiocephalic arteriovenous fistula

“…Severe symptomatic DASS more commonly occurs in patients with brachial artery origin, diabetes mellitus (DM) and female gender. Other risk factors include previous ipsilateral AVF, peripheral atherosclerosis and age [ 1 ]. The incidence of symptomatic DASS is much less common in AVF performed in the forearm compared with those in the arm ranging from 0.25 to 1.8% [ 2 ].…”