Not a Band-Aid Solution: Banding as First Line Therapy in Patients with Dialysis Access Steal Syndrome
Karthik Bhat, BS, Juhi Ramchandani, MS, Samuel Steerman, MD, David Dexter, MD, Jean Panneton, MD
Eastern Virginia Medical School, Norfolk, VA
Objectives:
Surgical options to treat dialysis access-related steal (DASS) syndrome include distal revascularization-interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. This study examines efficacy of banding for DASS and access patency.
Methods:
A retrospective analysis was performed on adults diagnosed with steal syndrome following hemodialysis access creation who underwent surgical banding of their dialysis access between January 1, 2009 and May 11, 2017. Patients <18 years and those with lower extremity accesses or HeRO grafts were excluded. Data was obtained using electronic medical records and analyzed using SPSS software. Primary endpoints were clinical symptom resolution, access patency, and change in digital brachial index. Banding was seen as a failure if the patient had persistent symptoms that required an operation. Steal was defined as recurrent if the patient had initial improvement of symptoms and had a secondary steal operation at a later date.
Results:
49 patients underwent access banding for correction of DASS. Demographics demonstrated 75.5% female (n=37), 59.2% African American (n=29), and 73.5% with grade 3 steal (n=36). Patients were followed for an average of 9.5 months (range 1-33 months). Complete symptom resolution was seen in 51.0% (n=25). Another 34.7% (n=17) had partial symptom resolution. The remaining 14.3% (n=7) showed no symptom improvement. Following banding, mean digital brachial index improved from 0.358 to 0.500 (p=0.006). Mean steal classification improved from 2.94 to 1.37 (p<0.001). Average time from access creation to banding was 10.4 months. Banding failed in 15 patients who were successfully retreated with one or more subsequent steal operations. Banding(3), DRIL(6), PAI(5), and Ligation(4) were utilized. Recurrent steal developed in two patients who were successfully treated with DRIL followed by Banding and a PAI. Average time to re-intervention for recurrent steal was 18 months. A banding first strategy ultimately lead to complete or partial symptom resolution in all patients. Following banding, 3 patients (6%) had circuit thrombosis within 60 days. Secondary patency was 85.7% at 1 year post-banding.
Conclusions:
Banding is a low risk procedure for treatment of DASS that doesn’t interfere with arterial circulation. While banding was shown to have 30% failure rate, it was associated with low rate of access thrombosis. If banding fails to resolve ischemic symptoms, revision surgery can be performed with high success rates.
Back to 2019 ePosters