Banding between dialysis puncture sites to treat severe ischemic steal syndrome in low flow autogenous arteriovenous access

Abstract

Dialysis-associated steal syndrome with rest pain and ischemic nonhealing ulcers dictates prompt surgical intervention. Distal revascularization with interval ligation is extensive surgery for frail patients in whom calcified distal arteries make anastomosis difficult. Simple banding is appropriate in high-flow fistulas. In low-flow accesses, further flow reduction by simple banding may result in inadequate dialysis and cause thrombosis. However, banding between puncture sites maintains a pressure gradient between the arterial and venous puncture sites that enables adequate flow with effective hemodialysis that would not be possible with banding at the anastomosis. This new technique is a good solution for maintaining access patency and increasing digital pressure while avoiding complicated surgical revisions in high-risk patients.

Hand Ischemia Associated With Dialysis Vascular Access: An Individualized Access Flow‐based Approach to Therapy

“…In performing preoperative evaluation for flow‐reduction surgery, some have proposed evaluating the patient by manually compressing the access while simultaneously assessing digital blood flow and measuring access blood flow using Doppler ultrasound. The goal is to achieve a digital pressure of at least 60 mmHg and/or a DBI of 0.5 while maintaining access blood flow adequate for effective dialysis.…”

“…The most common signs and symptoms associated with DASS are cold hand, hand pain, neuropathic problems of altered sensation, weakness and loss of function, and tissue loss. The beneficial effects of revascularization surgery on cold hand and pain symptoms have been immediate with immediate resolution in the 70–100% range . During the postoperative period, quick resolution of ischemic ulcers has generally been observed .…”

“…It should be noted that the mortality rate for patients with DASS is high as the comorbidities that are risk factors for DASS also impact life‐expectancy .…”

“…Although flow‐reduction procedures for treating DASS has typically been reserved for a high‐flow accesses, the minimum access blood flow necessary for banding is not well‐established. Some have recommended a value of 800 ml/minute . However, there are patients who have significant hemodynamic instability during hemodialysis .…”

Prediction of graft patency and mortality after distal revascularization and interval ligation for hemodialysis access-related hand ischemia

“…Our enthusiasm for the flow-limiting approaches is tempered by the inconsistent reports in the literature and the requisite, tenuous balance between adequate distal perfusion and sufficient access flow to sustain effective dialysis. However, the various flow limiting strategies may be effective for patients that have very high flow rates, particularly those with cardiac dysfunction 34 .…”