Dr Ravi BansalMD, DM Nephrology(AIIMS)

Consultant NephrologistPushpawati Singhania Research Institute

New Delhi

Steal syndrome-DefinitionClinical condition caused by arterial

insufficiency distal to a hemodialysis AV

access. Usually associated with reversal of

distal flow

Also called - Digital hypoperfusion

ischemic syndrome (DHIS) Severe ischemia:

Radial AV Fistula 1%Brachial AV Fistula or Graft 3-6%

Classification of steal syndrome Stage I Retrograde diastolic flow without

complaints; steal phenomenon

Stage II Pain on exertion and/or during

haemodialysis

Stage III Rest pain

Stage IV Ulceration/necrosis/gangrene

Eur J Vasc Endovasc Surg 2004; 27: 1–5

EtiologyTrue Steal from the Forearm Arteries

Can be clinically silent retrograde flow.

Presence of Occlusive Arterial Stenoses significant (50%) arterial stenoses commonly

seen in patients of hand ischemia. Incidence 62 to 100% by arteriography.

Distal ArteriopathyVascular calcification and diabetes

AssessmentRisk factors: Diabetes, PVD, Age , Brachial artery

fistula.

Dopplar ultrasound: with access compressed,

the post-stenotic flow pattern permits the

localization of a potential stenosis

Wrist or digital arterial pressures: below 50

mmHg

Digital(wrist)/brachial pressure DBI <0.6

Pulse oxymetry: O2 Sat <90%,

Arteriography

J Am Coll Surg 2000; 191: 301–310

Schanzer A et al.: Vascular Medicine 2006; 11:1-5

Clinical spectrumHand PainNumbness ( Diminished altered sensation)Pale , cold handDiminished or absent pulsesPoor capillary fillingSevere neuropathy (Ischemic Monomelic

Neuropathy)Atrophy, weaknessLoss of functionGangrene

Psri data123 patients screened and data collected:

For DM, CAD, Duration of AVFistula, location of

fistula, duration on HD, s/s to suggest ischemia

Hand Pain

68 diabetics, 35 CAD, avf (1 month to 8 yrs), 38%

brachial

Ischemic s/s in 8 patients. One patient with severe

ischemic changes.

Treatment Goal

Reversing the Ischemia

Preserving the Access

PreventionPre –op assessment

History of DM, PVDExam: Pulses, Bilateral BP, Allen’s Test,

DopplerAdditional Studies: Plethysmography/digital

pressures, flow, pulse oximetry, arteriography.Intra-op

Location and size of anastomosisIn high risk patients- intraop flow

measurement, digital pressures, pulse-oximetry

Treatment optionsPercutaneous interventions

percutaneous balloon angioplastyintravascular stent insertionintravascular coil insertionMILLER procedure - minimally invasive limited

ligation endoluminal-assisted revision Surgical interventions

banding procedureligation proceduretapered graft insertionPAI (Proximalization of the Arterial Inflow)DRIL- distal revascularization-interval ligationRUDI - revision using distal inflow

Classification of AV FistulaDepending on the flow values measured,

(i) ‘high flow’ (>800 ml/min in native fistulae, >1200 ml/min in access grafts),

(ii) ‘normal flow’ and

(iii) ‘low flow associated steal’ (<400 ml/min in native fistulae, <600 ml/min in access grafts) can be distinguished

Percutaneous Balloon Angioplasty

Detection of proximal arterial stenosisStudy of the arterial anatomy distal to AVaccess, for planning corrective procedure

Intravascular stent insertion

Treatment of steal syndrome in a distal radiocephalic arteriovenous fistula using intravascular coil embolization

JOURNAL OF VASCULAR SURGERY 2008 , 47(2), 457-9

ligation procedureAccess ligation will lead

to an immediate improvement of steal syndrome and also to the loss of the access with the need to create another one, again running the risk of provoking a steal syndrome.

in severe ischaemia or IMN

Banding ProcedureBanding aims at a reduction of access flow

for high flow associated steal syndrome.

when the degree of banding is controlled by intraoperative flow measurements (aiming at ∼400 ml/min in native fistulae and ∼600 ml/min in access grafts)

Banding

Banding a low flow access to a degree where steal syndrome disappears will result in inefficient dialysis or even access thrombosis

• excision of a portion of the vein and plication with mattress or continuous sutures

• crossed PTFE band

• interposition of a 4 mm PTFE

MILLER procedure - minimally invasive limited ligation endoluminal-assisted revision

Performed banding by tying a non-resorbable suture around the access over an inflated 4 or 5 mm dilatation balloon under fluoroscopic control to gain a defined reduction in the vessel diameter only in high flow associated steal

PAI (Proximalization of the Arterial Inflow)

Enhances access flow

Therefore in low flow associated steal syndrome

Zanow J, et al. J Vasc Surg 2006, 43:1216-1221

n=34Complete symptom relief=84%Secondary patency (1year)=90%

DRIL- distal revascularization-interval ligation

DRIL is a complex and time-consuming procedure,

possible only when a suitable vein can be harvested.

Can decrease flow by 25%>5 cm distance between the proximal

bypass anastomosis and the access anastomosis prevent retrograde diastolic flow in the graft

DRIL in AV Graft

RUDI - revision using distal inflow

In patients with high flow induced cardiac failure due to a brachial AV access,

closing the anastomosis in the antecubital fossa and interposing a graft between the forearm ulnar or radial artery has been shown to effectively reduce access flow by more than 50%

Treatment strategies of arterial steal after arteriovenous access.Gupta N et al

METHODS: Patients with ISS between June 2003 and

June of 2008 at the University of Pittsburgh Medical Center were retrospectively reviewed.

Success was defined as resolution of ISS symptoms while preserving access function.

J Vasc Surg. 2011 Jul;54(1):162-7. Epub 2011 Jan 26.

114 patients mean age of 65 years, female (66%), diabetic (61%), and

brachial fistula (69%). Risk factors coronary artery disease (CAD; P < .001),

hypertension (P < .001), and tobacco use (P = .048). Women had more brachial origin access (odds ratio [OR], 3.1;

P = .009). Forty-four patients with mild steal were observed. Seventy patients underwent 87 procedures. ligation (n = 27), banding (n = 22), DRIL (n = 21), improvement of proximal inflow (n = 9), revision using

distal inflow (RUDI; n = 4), and proximalization of arterial inflow (PAI; n = 3).

Early procedures (<30 days from the index fistula) were mostly ligation (50%) or banding (38%),

while DRIL was the most frequent choice for late interventions (41%).

Banding had a high failure rate (62%) and DRIL had a better success rate than banding (P ≤ .05).

ConclusionRisk factors for development of ISS include

CAD, diabetes, female gender, hypertension,

and tobacco use.

banding has a low success rate, while DRIL is

particularly effective

Less invasive treatment options such as RUDI

and PAI may be quite effective in treating ISS.

Algorithm to treat patients with symptoms ofdistal hypoperfusion ischemic syndrome

Am J Kidney Dis 48: 88–97, 2006

Thanks

Digital Pressure Measurement(Plethysmography)

Effect of compression of AVfistula on PPG curve

Flow-based Access Creation

32

Transonic (FMV) Vascular Flowprobes

Available in a wide range of sizes (1.5 to 14 mm)

ReusableSteam, ETO and Sterilizable

33

Flow-based Vascular Access Management

34

Intraoperative Flowmeter

Hemodialysis Monitor

Endovascular Flowmeter

intravascular coil insertion

Angiograms show sequential coiling of arteries supplying the arteriovenous fistula. A, Angiography after coil embolization of distal radial artery beyond the arteriovenous anastomosis shows subsequent retrograde filling by the superficial palmar branch ofthe radial artery and carpal artery. B, Subsequent angiography after coil embolization of the superficial palmar branch (SPB) of the radial artery and carpal artery (C) seen in image A, as well an additional carpal artery (C) supplying the fistula. RA, Radial artery

Diagnosis of ischemic steal-Digital pressure <60 mmHg (accuracy

92%, sens. 100%, spec. 87%)

-Brachial/Digital Index <0.4 (accuracy

94%, sens. 92%, spec. 94%)

-Digital pressure with compression is

20%> than without compression

Schanzer A et al.: Vascular Medicine 2006; 11:1-5

Ischemic Monomelic Neuropathy

Rare, Global ischemic neuropathySevere hand pain immediately post opSymptoms are out of proportion to degree of

ischemic findingsTreatment consists of immediate access

ligationPrognosis is poor