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Joseph Mills, MD September 27, 2012Chief3:25 pm – 3:45 pmDivision of Vascular andEndovascular SurgeryProfessorDepartment of SurgeryUniversity of ArizonaISCHEMIC STEAL, DIAGNOSIS ANDMANAGEMENTLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Manage ischemic steal syndrome and differentiate it from physiologicsteal.2. Diagnose ischemic by history, physical examination and simplenoninvasive tests.3. Identify patients at greatest risk for ischemic steal syndrome.109
Ischemic Steal Syndrome due to Hemodialysis Access ProceduresJoseph L. Mills, Sr., MDProfessor of SurgeryChief, Division of Vascular and Endovascular SurgeryUniversity of Arizona Health Sciences CenterTucson, Arizona 85724jmills@u.arizona.eduThis summary is based in large part on previously published work by the author and theUniversity of Arizona (see references).Background:An estimated 340,000 individuals with end stage renal disease are currentlymaintained on hemodialysis. Due to the Fistula First Initiative and improvements insystems of care, an increasing percentage of patients are dialyzed via an autogenousarteriovenous fistula (nearly 70% in our region). The remainder are dialyzed via cathetersor AV grafts. Both hemodialysis fistulae and grafts are associated with the developmentof ischemic steal syndrome (ISS), with a reported incidence of 1.6-8%. The purpose ofthis presentation is to review the risk factors for and hemodynamics of ischemic stealsyndrome and to detail effective techniques for diagnosis and management.Incidence and Presentation:The reported incidence of ISS ranges from 1.6 – 8%, although the true incidencemay be a bit higher due to lack of recognition and reluctance of clinicians to recognize allbut the most severe forms of the ISS spectrum. Preoperative factors that place individualsat increased risk for the development of ISS include: female gender, age > 60 years,diabetes, multiple operations on the same limb, construction of an autogenous fistula, andthe use of the brachial artery as the donor vessel. Mean patient age in the largest reportedseries is approximately 60 years and diabetes is present in about ¾ of patients with ISS.The development of ischemic symptoms distal to an arteriovenous (AV) fistulacan occur early (< 30 days) or late (>30 days) postoperatively. Although most symptomsoccurring acutely are self-limiting and resolve with observation, symptoms that occur lateare frequently progressive and demand more aggressive medical attention. Mostcommonly patients present with extremity coolness and vague neurosensory changes -often incorrectly diagnosed as diabetic neuropathy. In more severe cases, patients mayreport ischemic rest pain, ischemic ulceration of the digits, or intrinsic muscle weakness.Physical examination usually reveals diminished peripheral pulses, pallor, and evidenceof sensory or motor neuropathy. Because many of the signs and symptoms are rather nonspecific,clinicians should maintain a high index of suspicion in all patients with afunctioning AV fistula or graft who have distal extremity complaints.1101
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Program Book
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Needs AssessmentOver 370,000 patien
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ACKNOWLEDGEMENTSWe would like to th
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No relevant financial relationships
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2:25 pm Vascular Access Infections,
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ESRD in 2012: Socio-economicImpactJ
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Geographic variations in adjustedin
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Adjusted all-cause & cause specific
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ESRD-International ComparisonsPreva
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Outcomes for first-time wait-listed
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NOTES______________________________
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Vascular Access Planning andPreoper
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• Veins not circular but ovoid, m
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VENOGRAM+ -CFDI+ 17(true positive)-
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• Thorough preoperative assessmen
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NOTES______________________________
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Options and Strategies forUpper Ext
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Cimino (radiocephalic) AVFPotential
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Two Stage BBAVFStage 1 anastomosis
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Brachial Artery-Brachial Vein AVFSu
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Forearm AV GraftsLarge surface area
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Comparison of brachial-basilic AVfi
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Racial differences in AVfistula rat
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THANK YOU!46
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Lower ExtremityDialysis AccessAhmed
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Lower Extremity Dialysis AccessWhat
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Lower Extremity Dialysis AccessData
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Lower Extremity Dialysis AccessData
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Thank You!LLUMC56
Page 59 and 60: NOTES______________________________
Page 61 and 62: NOTES______________________________
Page 63 and 64: When to Break the Guidelines in Vas
Page 65 and 66: efore initiation of dialysis. It fu
Page 67 and 68: NOTES______________________________
Page 69 and 70: Vascular AccessSurveillanceIs it wo
Page 71 and 72: Monitoring Vs. SurveillanceClinical
Page 73 and 74: Vascular Access Surveillance• Obs
Page 75 and 76: Vascular Access SurveillanceRandomi
Page 77 and 78: Vascular Access SurveillanceRandomi
Page 79 and 80: So why does preemptiveangioplasty n
Page 81 and 82: • ConclusionAccess Surveillance
Page 83 and 84: Management of the Non-MaturingArter
Page 85 and 86: Specific Definition• “…use of
Page 87 and 88: AVF Maturation in Clinical Practice
Page 89 and 90: Hemodialysis Fistula MaturationCons
Page 91 and 92: Physical Exam of AVF• Has an accu
Page 93 and 94: Significant Accessory VeinsSurgical
Page 95 and 96: Venous Stenosis in AVF Body/Outflow
Page 97 and 98: Deep or Excessively Tortuous AVF•
Page 99 and 100: Robert Hye, MD September 27, 2012Ka
Page 101 and 102: Influence of Access Type onInfectio
Page 103 and 104: Prevention of HemodialysisAccess In
Page 105 and 106: Summary of CatheterManagement in CR
Page 107 and 108: Partial versus Total GraftExcision
Page 109: Infected Autogenous DialysisFistula
Page 113 and 114: Figure 2: (From JACS 2000: Wixon et
Page 115 and 116: Theoretically the presence of a lar
Page 117 and 118: Treatment of Ischemic Steal Syndrom
Page 119 and 120: performing a femoral-femoral bypass
Page 121 and 122: Ligation may still be an option for
Page 123 and 124: arterio-venous fistula. Acta Chir S
Page 125 and 126: David Shavelle, MD September 27, 20
Page 127 and 128: Definitions• Early (Primary) Fail
Page 129 and 130: Dual-Sheath TechniqueStep 1: Thromb
Page 131 and 132: Role of Stent Placement• Stenting
Page 133 and 134: ComplicationsPulmonary Embolism~10%
Page 135 and 136: PrePostMedical Therapy• Clopidogr
Page 137 and 138: Karen Woo, MD September 27, 2012Ass
Page 139 and 140: Dilation occurs over several years
Page 141 and 142: Replace with interposition graft◦
Page 143 and 144: Heparin Proximal and distal control
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Page 147 and 148: Perioperative variableOperative tim
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Page 151 and 152: POLICY ON CULTURAL AND LINGUISTIC C
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