Vascular access steal syndrome explained

Specialty:	nephrology

In nephrology, vascular access steal syndrome is a syndrome caused by ischemia (not enough blood flow) resulting from a vascular access device (such as an arteriovenous fistula or synthetic vascular graft–AV fistula) that was installed to provide access for the inflow and outflow of blood during hemodialysis.

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.

Symptoms are graded by their severity:^[3]

• Grade 0: No symptoms of steal
• Grade 1: Mild - cool extremity, improvement in hand pulse with access occlusion
• Grade 2: Moderate - Ischemic symptoms during dialysis
• Grade 3: Severe - Ischemic hand pain outside of dialysis; Ulcers or gangrene of the fingers

Diagnosis

• History and physical exam - relief of symptoms with compression of the fistula on exam is highly suggestive of steal
• Arteriography^[4]
• Duplex ultrasound

Treatment

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

Revascularization techniques

• Distal Revascularization and Interval Ligation (DRIL) procedure
• PAI (Proximalization of the Arterial Inflow)^[5]
• RUDI (Revision Using Distal Inflow)^[6]

Banding techniques

• Narrowing suture^[7]
• Plication^[8]
• Minimally invasive MILLER banding^[9]
• Tapering^[10]
• Surgical banding^[11]

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.

Incidence

DASS occurs in about 1% of AV fistulas and 2.7-8% of PTFE grafts.^{[12] [13]}

Terminology

Within the contexts of nephrology and dialysis, vascular access steal syndrome is also less precisely just called steal syndrome (for short), but in wider contexts that term is ambiguous because it can refer to other steal syndromes, such as subclavian steal syndrome or coronary steal syndrome.

See also

• Terms for anatomical location

References

1. Porcellini M, Selvetella L, De Rosa P, Baldassarre M, Bauleo A, Capasso R . [Hand ischemia due to "steal syndrome" in vascular access for hemodialysis] . G Chir . 18 . 1–2 . 27–30 . 1997. 9206477.
2. Shemesh D, Mabjeesh NJ, Abramowitz HB . Management of dialysis access-associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction . J Vasc Surg . 30 . 1 . 193–5 . 1999 . 10394170 . 10.1016/S0741-5214(99)70192-8. free .
3. Book: Harris . Linda . Heodialysis Access: Nonthrombotic complications . In: Rutherford's Vascular SUrgery . 1141–1152 . 8.
4. Asif A, Leon C, Merrill D, Bhimani B, Ellis R, Ladino M, Gadalean F . Arterial steal syndrome: a modest proposal for an old paradigm . Am J Kidney Dis . 48 . 1 . 88–97 . 2006 . 16797390 . 10.1053/j.ajkd.2006.03.077. free .
5. Zanow J, Kruger U, Scholz H . Proximalization of the arterial inflow: a new technique to treat access-related ischemia . J Vasc Surg . 43 . 6 . 1216–21 . 2006 . 16765242 . 10.1016/j.jvs.2006.01.025. free .
6. Minion DJ, Moore E, Endean E . Revision using distal inflow: a novel approach to dialysis-associated steal syndrome . Ann Vasc Surg . 19 . 5 . 625–8 . 2005 . 16052391 . 10.1007/s10016-005-5827-7. 24275191 .
7. J.C. West . D.J. Bertsch . S.L. Peterson . M.P. Gannon . G. Norkus . R.P. Latsha . Kelley SE. . Arterial insufficiency in hemodialysis access procedures: correction by "banding" technique . Transpl Proc . 23 . 2 . 1838–40 . 1991 . 2053173.
8. S.P. Rivers . L.A. Scher . F.J. Veith. . Correction of steal syndrome secondary to hemodialysis access fistulas: a simplified quantitative technique . Surgery . 112 . 3 . 593–7 . 1992 . 1519174.
9. Goel N, Miller GA, Jotwani MC, Licht J, Schur I, Arnold WP . Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome . Kidney Int . 70 . 4 . 765–70 . 2006 . 16816841 . 10.1038/sj.ki.5001554. free .
10. Kirkman RL. . Technique for flow reduction in dialysis access fistulas . Surg Gyn Obstet . 172 . 3 . 231–3 . 1991 . 1994500.
11. Anderson CB, Groce MA . Banding of arteriovenous dialysis fistulas to correct high-output cardiac failure . Surgery . 78 . 5 . 552–4 . 1975 . 1188596.
12. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB . Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure . J Surg Res . 74 . 1 . 8–10 . 1998 . 9536965 . 10.1006/jsre.1997.5206.
13. Goff CD, Sato DT, Bloch PH, DeMasi RJ, Gregory RT, Gayle RG, Parent FN, Meier GH, Wheeler JR . Steal syndrome complicating hemodialysis access procedures: can it be predicted? . Ann Vasc Surg . 14 . 2 . 138–44 . 2000 . 10742428 . 10.1007/s100169910025. 33823722 .