Program Book - Keck School of Medicine of USC - University of ...

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