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Volume Flow Reduction Using Distal Inflow Provides Excellent Intermediate Outcome for Patients with Functioning Autogenous AV Fistula and Dialysis Access Steal Syndrome
Tam T. Huynh, M.D.1, Eric K. Peden, M.D.2, Javier E. Anaya-Ayala, M.D.2, Mark G. Davies, MD, PhD, MBA2, Joseph J. Naoum2.
1University of Texas MD Anderson Cancer Center and The Methodist Hospital, Houston, TX, USA, 2The Methodist Hospital, Houston, TX, USA.

Objectives:
Dialysis access steal syndrome (DASS) is the most common cause of critical upper extremity ischemia. The management of DASS remains challenging and controversial. Revision using distal inflow (RUDI) has been described in case reports to treat DASS. We report our experience with volume flow (VF) reduction using distal inflow to preserve autogenous arteriovenous fistula (AVF) and alleviate DASS.
Methods:
We retrospectively review consecutive patients who underwent RUDI for DASS from January 2010 to August 2011. Data collection included pre-operative clinical factors, operative details, and post-operative outcome of AVF patency, symptomatic relief, and complications.
Results:
15 patients (9 women and 6 men) had RUDI for DASS (mean age was 54 year-old; range 25 - 83). 80% were diabetic (12/15). All patients had symptoms of hand/digit pain, numbness, coldness, and 4 had tissue loss. Mean interval from the time of AVF creation or recent intervention (e.g. transposition) to RUDI was 12 months (range 2 - 22). Ten patients had brachio-cephalic and 5 brachio-basilic AVF. Twelve patients had a functional AVF when RUDI was done; AVF not yet mature in 3 (20%). Pre-operative duplex and digit photoplethysmography evaluation showed steal in all patients, and mean VF was 1733 (range 800 - 3192 ml/min ). Inflow for RUDI was the radial artery in 8 patients and ulnar in 7. Vein graft interposition was used in 9, and revised direct AV anastomosis in 6 patients. Mean length of post-operative hospital stay was one day (range 0-5) and follow-up time is 10 months (range 1-20). All patients reported immediate symptomatic relief. RUDI salvaged all 12 functional AVF but failed to preserve the 3 non-functional AVF ; 1 was ligated at 3 weeks due to wound necrosis, 1 patient died of a myocardial infarction at 3 months, and 1 did not mature. Post-operative duplex showed mean VF reduction of 48% (range 23 - 65%); mean VF was 952 (312-2472 ml/min).
Conclusions:
Our results show that RUDI is effective in alleviatting DASS by reducing VF and preserves functioning AVF. Based on our preliminary results, we recommend RUDI for functioning AVF with VF > 800 ml/min but not for AVF that are not yet mature. Larger future studies regarding the long-term outcome and comparing RUDI to other interventions for DASS are still needed.


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