Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies

Abstract

Distal hypoperfusion ischemic syndrome (DHIS), commonly referred to as hand ischemia or “steal” after dialysis access placement, occurs in 5–10% of cases when the brachial artery is used, or 10 times that of wrist arteriovenous fistulas (AVFs) using the radial artery. It is typically seen in elderly women with diabetes, and may carry severe morbidity including tissue or limb loss if not recognized and treated. Three distinct etiologies include (1) blood flow restriction to the hand from arterial occlusive disease either proximal or distal to the AV access anastomosis, (2) excess blood flow through the AV fistula conduit (true steal), and (3) lack of vascular (arterial) adaptation or collateral flow reserve (ie atherosclerosis) to the increased flow demand from the AV conduit. These three causes of steal may occur alone or in concert. The diagnosis of steal is based on an accurate history and physical examination and confirmed with tests including an arteriogram, duplex Doppler ultrasound (DDU) evaluation with finger pressures and waveform analysis. Treatment of steal includes observation of developing symptoms in mild cases. Balloon angioplasty is the appropriate intervention for an arterial stenosis. At least three distinct surgical corrective procedures exist to counteract the pathophysiology of steal. The ultimate treatment strategy depends on severity of symptoms, the extent of patient co-morbidity, and the local dialysis access technical team support and skills available.

Tratamento da síndrome de roubo de fístula arteriovenosa pela técnica de revascularização distal e ligadura arterial: relato de três casos

“…The ischemic symptoms may be caused by the severity of atherosclerotic disease distal to the arteriovenous anastomosis 9 . The diagnosis is based on the clinical presentation: a pale and cold extremity, with weak pulses distal to the access, limb claudication, possibly paresthesia and trophic lesions 11 . A drop in wrist-brachial index (WBI) may be detected at Doppler ultrasonography.…”

Comparative Doppler flow measurements of the ulnar artery and of the postanastomotic radial artery in radiocephalic arteriovenous fistulas to detect steal syndromes

“…A classification of the symptoms has been suggested, similar to that of Leriche and Fontaine for ischemia of the lower limbs (Table I) (1,12). Paucisymptomatic forms generally develop rather quickly and their slow involution is the rule whereas severe attacks occur later and have a tendency to worsen (4).…”

“…In these instances and contrarily to ischemia attacks caused by blood diversion, the hand remains warm (1,4).…”

“…First of all, the anastomosis of the artery to the vein, a low resistance system, implies de facto a vascular steal that is the more important as the fistula flow is high; this implies that brachial fistulas, which are known to have a larger flow, are more often burdened with steal syndromes than wrist fistulas (1,4,7,(9)(10)(11). The second mechanism of distal ischemia is a proximal or a distal stenosing arterial lesion, whether it be arteriosclerotic, favored by uremia, dyslipemia or even smoking, or diabetic microangiopathic (1,4,7,12). The third offending mechanism is venous hyperpressure occurring when a significant stenosis develops in the venous segment of the fistula (4).…”

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

“…In hemodialyzed patients with arteriovenous fistulas (AVF) the presence of pain, numbness and/or cold extremity in the limb that bears the fistula is referred to as digital hypo-perfusion ischemic syndrome (DHIS) (1). Previously DHIS was known as arterial theft syndrome however now it is clear that more factors stand at the basis of DHIS development.…”