Back to 2015 Annual Symposium Program

OBJECTIVES: Ischemic steal syndrome (ISS) is a dreaded complication following hemodialysis access creation. Its management is complex and varied with a majority requiring surgical revision for correction of symptoms. Proximalization of arterial inflow (PAI) is an alternative to distal revascularization-interval ligation (DRIL) that obviates the need to ligate the axial artery. We present our experience, of PAI for the treatment of ISS.
METHODS: We retrospectively reviewed consecutive patients who underwent PAI for ISS from April 2008 to June, 2014. Data collection included demographics, past medical histories, subsequent procedures, volume flows, access usage, limb salvage and patient survival.
RESULTS: We performed 38 PAI (21 women, 17 men). Indications for surgery were extremity pain in 38 patients, neurologic dysfunction in 18 patients and tissue loss in 4 patients. 29% had prior surgical intervention for ISS. 74% of patients had a history of diabetes. 49% had a history of atherosclerotic disease. Time to intervention from creation was 23 months (range, 1-94). Accesses included 9 radiocephalic, 26 brachiocephalic and 3 brachiobasilic fistulas. Proximalization targets were 1 radial artery, 3 ulnar arteries and 34 proximal brachial arteries. Primary assisted patency at 1 year was 71%. Secondary patency at 1 year was 74%. Symptom resolution was reported as complete in 69% and markedly improved in 22%. 6 patients underwent subsequent procedures for continued symptoms with 4 fistulas ultimately ligated for ISS. The average flow in the 4 ligated fistulas increased by 629cc/min (remaining fistulas, average decreased flow of 101cc/min).
CONCLUSIONS: PAI is an effective and durable treatment for ISS without ligating axial flow to the extremity. Early results are concerning that PAI can potentially increase flow to the access inducing further steal. Patient selection and monitoring of post-op flow is key for optimizing relief of symptoms and maintaining use of the access. Further investigation into intraop flow monitoring or combination Proximalization/plication are needed.