Huber - VascularWeb

Access-related Hand Ischemia
Thomas S. Huber, MD, PhD
Professor of Surgery
University of Florida College of Medicine
Gainesville, Florida
Postgraduate Course – SVS Annual Meeting
Boston, Massachusetts

Disclosures
None

Introduction
• Hand ischemia - most worrisome
“complication” after hemodialysis access.
• Spectrum of symptoms (mild → severe).
• “Complication” or adverse hemodynamic
event within standard of care.
*Access surgeons must be familiar with predictors, diagnosis, and treatment

Definitions and Classifications
• Multiple terms and acronyms.
– Access related ischemia (ARI)
– Access related hand ischemia (ARHI)
– Ischemic steal syndrome (ISS)
– Dialysis associated steal syndrome (DASS)
– Hemodialysis access induced distal ischemia (HAIDI)
– Distal hypoperfusion ischemic syndrome (DHIS)
*commonly described simply as “steal syndrome”

Definitions and Classifications
• SVS Reporting Standards – “Steal”
0 – none
1 – mild cool extremity with few symptoms
2 – moderate, ischemia during dialysis
3 – severe, rest pain/tissue loss
J Vasc Surg 2002;35:603.

Pathophysiology and Risk Factors
• Low resistance circuit.
• Distal perfusion
variable, based on
collaterals.
• “Physiologic steal”
usually tolerated.
• Inflow/forearm PAOD
decrease perfusion.
*80% of patients with DBI – Vasc Endovasc Surg 2003;37:179

Pathophysiology and Risk Factors
• Incidence (brachial artery-based access).
– Symptoms 20%.
– Intervention 10%.
• Natural history poorly defined (selection).
– Mild symptoms may improve.
– Mod/serve symptoms do not improve.
– Close follow-up mandatory
*ischemia after radial-artery based access

Pathophysiology and Risk Factors
• Clinical predictors
– Advanced age
– Female gender
– Diabetes
– Large conduit
– PVOD
– Multiple prior accesses
– Prior hand ischemia
• Noninvasive imaging
– Finger pressure
– DBI
*Clinical factors, noninvasive studies with poor positive predictive value.

Clinical Presentation and Diagnosis
• Classic symptoms
(acute/chronic).
• Clinical diagnosis –
caution with pulses.
• Limited differential.
• Dialysis history key.
• Noninvasive studies
supportive.

Indications and Treatment
• Goal - reverse ischemia/preserve access.
• Indications – moderate/severe ischemia.
• Multiple (complementary) treatments.
*Ischemic neuropathy may not be reversible.

Indications and Treatment
• Access ligation.
• Correct inflow stenosis.
• Flow-limiting (e.g. “banding”).
• Proximalization of arterial inflow (PAI).
• Ligation of artery distal to anastomosis.
• Distal revascularization/interval ligation (DRIL).
• Distal revascularization without ligation

Indications and Treatment
• Hemodynamic impact – ex vivo.
– Flow limiting effective.
– DRIL and PAI with dramatic effect.
– Ligation component of DRIL minimal effect.
J Vasc Surg 2008;48:1559
Ann Vasc Surg 2004;18:59

Indications and Treatment
• Clinical determinants of treatment.
– Cause of ischemia (possible inflow).
– Potential utility of access.
– Future access options (recurrence).
– Patient comorbidities.
– Available conduit.
*DRIL for acute symptoms and reasonable autogenous access

Indications and Treatment
• “Flow limiting” (banding).
– Abandoned resurgence.
– Balance perfusion/access flow.
– Hemodynamics/biology dynamic.
– Potential with objective measurements for
“high flow” accesses (> 1.2 L/min)
*Not effective for extensive tissue loss.
J Vasc Surg 2006;44:1273
Arch Surg 2007;392:204

Indications and Treatment
• Proximalization of arterial inflow (PAI)
– Variant of “flow limiting” procedure.
– Does not require ligating axial artery.
– Potential for patients without conduit.
– Autogenous → prosthetic access.
– Limited published experience.
*Not effective for extensive tissue loss.
J Vasc Surg 2006;43:1216
Ann Vasc Surg 2008;23:485

Indications and Treatment
• Distal revascularization/interval ligation
– Most accepted/durable.
– Requires ligating axial artery.
– Hand dependent upon bypass.

Indications and Treatment
• Preoperative (preemptive) planning.
– Identify/correct all inflow lesions.
– Operative plan to limit ischemia.
– Remedial plan for ischemia.
– Potential vein survey for DRIL.

UF DRIL - Patients
Demographics N = 61
Age 59 13
Gender (% female) 62%
Comorbidities
ESRD 92%
Hypertension 74%
Diabetes Mellitus 72%
Coronary Artery Disease 36%
Congestive Heart Failure 20%
Prior Access-related Ischemia 10%
*6% of new access procedures required DRIL – J Vasc Surg 2008;48:926

UF DRIL - Procedures
Auto Radiocephalic 0
Auto Radiobasilic 0
Auto Brachiocephalic 46%
Auto Brachiobasilic 31%
Auto BA Translocated Femoral 20%
Prosthetic Brachioaxillary 3%
J Vasc Surg 2008;48:926

Percentage (%)
UF DRIL – Presenting Symptoms
50
40
34
30
25
24
20
17
10
0
Pain Paresthesia Motor Tissue
Loss
*Preemptive DRIL N = 5
J Vasc Surg 2008;48:926

Percentage (%)
UF DRIL – Timing of Procedure
50
44
40
30
29
20
19
10
0
< 1 day 1 - 7 days 7 - 30 days > 30 days
8
J Vasc Surg 2008;48:926

UF DRIL - Technique
• Proximal bypass
anastomosis > 7cm
from fistula.
• Distal anastomosis
functional end/end to
brachial artery.
• Autogenous v > 3 mm.
• Inflow arteriogram.
J Vasc Surg 2008;48:926

UF DRIL - Outcome
Mortality 3%
Morbidity 22%
Wound 14%
Respiratory 3%
Vascular 3%
Cardiac 2%
J Vasc Surg 2008;48:926

UF DRIL - Outcome
Paresthesia
Motor
Tissue Loss
Pain
None
*Ischemic neuropathy may not be reversible.
J Vasc Surg 2008;48:926

UF DRIL - Outcome
1
0.8
* *
0.79
0.7
0.6
0.4
0.46
0.25
Pre
Post
0.2
0
WBI
FBI
J Vasc Surg 2008;48:926

UF DRIL - Outcome
Access – Immature
(67%)
Access – Mature
(33%)
Mature - 68% Fail - 32%
Continue – 100% Early Failure - 0
J Vasc Surg 2008;48:926

J Vasc Surg 2008;48:926

J Vasc Surg 2008;48:926

Summary/Conclusions
• Access-related hand ischemia is an
adverse hemodynamic event.
• Predictable based upon patient
characteristics and noninvasive studies.
• Clinical diagnosis corroborated with
noninvasive studies.

Summary/Conclusions
• Goal to reverse ischemia/salvage access.
• Multiple complementary treatment options
• DRIL is a safe, effective treatment.
– Symptomatic relief > 90%.
– Acceptable bypass graft patency.
– Preserves both hand and access.

Go GATORS

Case Presentation
• HPI – 51 yo thin male with history of ESRD. Multiple
failed LUE access procedures.
• PMH – noncontributory.
• PE – 2+ bilateral brachial/radial pulses. Multiple surgical
incisions, palpable prosthetic access.
• Vascular laboratory – no suitable peripheral veins,
arterial pressures equal/symmetric, no central vein
problems

Case Presentation - Continued
• Surgical procedure – R brachioaxillary
prosthetic access with 6 mm PTFE.
• Perioperative outcome – grade III hand
ischemia.
• Vascular laboratory – no LE vein.

Case Presentation - Continued
• Remedial treatment – arteriogram without
inflow lesion, definitive treatment with
ligation.
• Approach to subsequent access.

Case Presentation
• HPI – 60 year old obese female with ESRD for
13 years, 57 prior access-related procedures
currently dialyzing through a brachioaxillary
prosthetic access (8 mm PTFE), venous
anastomosis infraclavicular. Access noted be
occluded at dialysis unit.
• PE – obese female, multiple arm incisions,
obvious graft thrombosis.

Case Presentation - Continued
• Surgical procedure – open mechanical
thrombectomy, venogram with central vein
occlusion.

Case Presentation - Continued
• Surgical procedure – central vein
angioplasty with 14 mm balloon.
• Remedial treatment