Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome

Abstract

Dialysis-associated steal syndrome (DASS) is defined as a clinical condition caused by arterial insufficiency distal to the dialysis access owing to diversion of blood into the fistula or graft. The incidence of symptomatic DASS requiring treatment is 1-8%. The etiology is iatrogenic and symptoms are quite debilitating. Banding of the access inflow has largely been abandoned because of the inherent problem with balancing fistula flow with distal flow complicated by a high incidence of subsequent access thrombosis. In this study, we are reporting a modification to the traditional banding procedure, which markedly improves banding outcomes. We are reporting 16 patients who underwent a new standardized minimally invasive banding procedure performed in an outpatient setting with minimal morbidity. This modified banding procedure requires a small (1-2 cm) skin incision for the placement of a ligature and utilizes a 4 or 5 mm diameter endoluminal balloon to achieve and standardize the desired reduction of inflow size. All 16 patients had immediate symptomatic and angiographic improvement after the procedure. Follow-up showed none of the patients had recurrence of symptoms or thrombosis of the access. In our experience, this procedure is an excellent treatment option because of its simplicity and should be considered as a first-line treatment for patients with DASS.

Distal Revascularization and Interval Ligation: A Primer for the Vascular and Interventional Radiologist

“…The dialysis access can also be narrowed by the MILLER technique, which uses a balloon to serve as a template for the Miller ligature to narrow the dialysis access. 9,10 Recently, Zangan and Van Ha described using a constrained Wallstent 1 (Boston Scientific, Natick, MA) narrowed to 4 mm by a suture as a minimally invasive technique to increase resistance within the fistula 9 for the treatment of dialysis access steal.…”

“…8 The development of hand ischemia that requires further surgical intervention is between 5 to 8%. [1][2][3][4][5][6][7]9,10 Many surgical options have been described for the treatment of dialysis-associated arterial steal syndrome. The distal revascularization interval ligation (DRIL) procedure has quickly become a desirable treatment option for dialysis-associated arterial steal syndrome.…”

“…1 Steal is more likely when the access is placed above the brachial artery trifurcation. 9,10 Other risk factors such as advanced age, female sex, peripheral arterial occlusive disease, large conduits such as femoral or popliteal veins, or history of multiple prior procedures have also been described. 1,[3][4][5]11 During the placement of the initial dialysis access, an intraoperative digital-brachial index of less than 0.45 is also a risk factor for the subsequent development of hand ischemia.…”

Stenotic ligature: a simple technique for managing distal hypoperfusion ischemic syndrome following arteriovenous fistulas

“…The need for a re-intervention can be predicted by the absence of radial pulse before the anastomosis, as shown in the paired analysis (p=0.027). Goel et al 6 Miller 94% 16 Table 4. Literature comparison regarding success rate after various surgical procedures for DHIS correction After an arteriovenous anastomosis some degree of hypoperfusion clearly develops as flow is shunted in a low resistance area created by the fistula.…”

“…Otherwise, distal flow can be increased by reducing arterial theft (5). A percutaneous procedure addressing this cause with good results is the minimally invasive limited ligation endoluminal assisted revision (Miller) (6). The technique is based on the application of a Nylon ligature around an inflated endoluminal balloon.…”