Vascular access steal syndrome

In nephrology, vascular access steal syndrome or Dialysis-associated Steal Syndrome (DASS), also known less precisely as steal syndrome, refers to vascular insufficiency resulting from an arteriovenous fistula or synthetic vascular graft-AV fistula).

Signs

• Pallor
• Diminished pulses (distal to the fistula)
• Necrosis^[1]
• Decreased wrist-brachial index (ratio of blood pressure measured in the wrist and the blood pressure measured in the upper arm), especially if below 0.6^[2]

Symptoms

• Pain distal to the fistula.

Incidence

DASS occurs in about 1% of AV fistulas and 2.7-8% of PTFE grafts.^[3][4]

Investigations

• Arteriography^[5]

Treatment

The fistula flow can be restricted through banding, or modulated through surgical revision.

Revascularization techniques

• DRIL (Distal Revascularisation and Interval Ligation) procedure
• PAI (Proximalization of the Arterial Inflow)^[6]
• RUDI (Revision Using Distal Inflow)^[7]

Banding techniques

• Narrowing suture^[8]
• Plication^[9]
• Minimally invasive MILLER banding^[10]
• Tapering^[11]
• Surgical banding^[12]

If the above methods fail, the fistula is ligated, and a new fistula is created in a more proximal location in the same limb, or in the contralateral limb.

See also

• Subclavian steal syndrome
• Terms for anatomical location

References

1. Porcellini M, Selvetella L, De Rosa P, Baldassarre M, Bauleo A, Capasso R (1997). "[Hand ischemia due to "steal syndrome" in vascular access for hemodialysis]". G Chir 18 (1–2): 27–30. PMID 9206477.
2. Shemesh D, Mabjeesh NJ, Abramowitz HB (1999). "Management of dialysis access-associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction". J Vasc Surg 30 (1): 193–5. doi:10.1016/S0741-5214(99)70192-8. PMID 10394170.
3. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. (1998). "Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure". J Surg Res 74 (1): 8–10. doi:10.1006/jsre.1997.5206. PMID 9536965.
4. Goff CD, Sato DT, Bloch PH, DeMasi RJ, Gregory RT, Gayle RG, Parent FN, Meier GH, Wheeler JR. (2000). "Steal syndrome complicating hemodialysis access procedures: can it be predicted?". Ann Vasc Surg 14 (2): 138–44. doi:10.1007/s100169910025. PMID 10742428.
5. Asif A, Leon C, Merrill D, Bhimani B, Ellis R, Ladino M, Gadalean F (2006). "Arterial steal syndrome: a modest proposal for an old paradigm". Am J Kidney Dis 48 (1): 88–97. doi:10.1053/j.ajkd.2006.03.077. PMID 16797390.
6. Zanow J, Kruger U, Scholz H. (2006). "Proximalization of the arterial inflow: a new technique to treat access-related ischemia". J Vasc Surg 43 (6): 1216–21. doi:10.1016/j.jvs.2006.01.025. PMID 16765242.
7. Minion DJ, Moore E, Endean E. (2005). "Revision using distal inflow: a novel approach to dialysis-associated steal syndrome". Ann Vasc Surg 19 (5): 625–8. doi:10.1007/s10016-005-5827-7. PMID 16052391.
8. J.C. West, D.J. Bertsch, S.L. Peterson, M.P. Gannon, G. Norkus and R.P. Latsha, Kelley SE. (1991). "Arterial insufficiency in hemodialysis access procedures: correction by "banding" technique". Transpl Proc 23 (2): 1838–40. PMID 2053173.
9. S.P. Rivers, L.A. Scher and F.J. Veith. (1992). "Correction of steal syndrome secondary to hemodialysis access fistulas: a simplified quantitative technique". Surgery 112 (3): 593–7. PMID 1519174.
10. Goel N, Miller GA, Jotwani MC, Licht J, Schur I, Arnold WP. (2006). "Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome". Kidney Int 70 (4): 765–70. doi:10.1038/sj.ki.5001554. PMID 16816841.
11. Kirkman RL. (1991). "Technique for flow reduction in dialysis access fistulas". Surg Gyn Obstet 172 (3): 231–3. PMID 1994500.
12. Anderson CB, Groce MA. (1975). "Banding of arteriovenous dialysis fistulas to correct high-output cardiac failure". Surgery 78 (5): 552–4. PMID 1188596.