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Hemodialysis access-induced distal ischemia

Hemodialysis access-induced distal ischemia
Literature review current through: Jan 2024.
This topic last updated: Oct 27, 2023.

INTRODUCTION — Ischemic complications of hemodialysis arteriovenous (AV) access are uncommon but can result in significant limb dysfunction or even limb loss. Ischemia can occur for a variety of reasons that almost always include decreased blood flow to the distal extremity resulting from blood flow through the AV fistula or AV graft. Preemptive strategies may mitigate the development of ischemic complications and should be considered in high-risk patients.

The incidence and timing for the development of hemodialysis access-induced distal ischemia (HAIDI), also called dialysis access steal syndrome (DASS), vary with the type and location of the access, and clinical symptoms can be graded from mild to severe. HAIDI is a more descriptive term of the multiple causes of access induced ischemia including DASS. In addition, HAIDI can present with high or low AV access volume flow, requiring individualized treatment algorithms. Ischemic monomelic neuropathy (IMN) is a variant that may lead to irreversible neurologic deficits and requires an aggressive management strategy. Treatment options for HAIDI include AV access ligation for severe ischemia, banding procedures to reduce flow in high-flow AV access, or procedures to modify access hemodynamics to improve distal blood flow [1].

The clinical features, diagnosis, and treatment of HAIDI, including DASS and the variant IMN, are reviewed. Other complications related to hemodialysis AV access and general techniques for their creation are reviewed separately. (See "Arteriovenous fistula creation for hemodialysis and its complications" and "Arteriovenous graft creation for hemodialysis and its complications".)

INCIDENCE, RISK FACTORS, AND PREVENTION — Hemodialysis access-induced distal ischemia (HAIDI) manifesting as a symptomatic steal syndrome is reported to occur in 4 to 10 percent of patients undergoing vascular access for hemodialysis, with wide variations in the incidence reported in the literature [2-5]. In a large series of 4863 patients, the incidence of ischemia relative to type of arteriovenous (AV) access was reported as follows [6]:

Snuffbox AV fistula: 0 percent

Radiocephalic AV fistula: 0.3 percent

Brachiocephalic AV fistula: 0.9 percent

Brachiobasilic AV fistula: 3.7 percent

Brachiocephalic/basilic AV fistula: 5.2 percent

Polytetrafluoroethylene AV graft: 2.2 percent

In a separate review of 602 patients from the Hemodialysis Fistula Maturation Study, the overall incidence of dialysis access steal syndrome (DASS) was 7 percent with 4 percent of patients experiencing symptoms sufficiently severe to warrant surgical intervention [7].

Risk factors — Identifying patients who have risk factors for developing HAIDI is important so that preemptive measures can be considered to reduce the risk of ischemic complications [8]. (See 'Strategies for prevention' below.)

In a review of 325 upper extremity procedures in which the overall incidence of steal was 6.2 percent, univariate analysis identified brachial artery inflow, diabetes, female sex, coronary heart disease, cerebrovascular disease, and age over 60 as risk factors for the development of steal [4]. Other risk factors identified in separate reviews include hypertension, capacitant outflow veins, and tobacco use [7-9].

Strategies to avoid brachial artery inflow for hemodialysis AV access should be considered, but efforts to predict the development of HAIDI in individual patients have been unsuccessful. A digital brachial index less than 0.6 identifies patients at risk for steal syndrome, but intraoperative measurement of digital brachial index cannot be used to reliably predict who will develop ischemia [10]. Similarly, preoperative finger pressures are lower in patients who develop ischemia, but there is no threshold pressure below which steal is inevitable [11].

Atherosclerotic vascular disease can be a risk factor for steal but is also a risk factor for digital gangrene. In a small review of 23 patients with finger gangrene, 45 percent had a functional ipsilateral AV fistula [12]. Patients were mostly young and had diabetes, and arteriography uniformly demonstrated diffuse atherosclerosis involving the radial, ulnar, palmar, and digital arteries precluding attempts at distal arterial bypass. Noninvasive testing with AV fistula compression failed to improve digital blood flow. The authors concluded that finger gangrene in this younger patient population was the result of distal atherosclerosis and rarely primarily related to the hemodialysis AV access.

Strategies for prevention — Although it remains impossible to predict the development of HAIDI in individual patients, specific strategies can be implemented to minimize the risk. These include preemptive identification of arterial disease and avoiding using the brachial artery as an inflow vessel.

Identifying correctable arterial lesions — Although proximal arterial disease as a cause of HAIDI is uncommon, it can be easily identified and treated to reduce the development of steal or to successfully treat symptomatic steal after AV access placement [13]. (See "Patient evaluation prior to placement of hemodialysis arteriovenous access", section on 'Arterial evaluation'.)

Preoperative noninvasive testing should include, at a minimum, a full upper extremity pulse examination, bilateral upper extremity blood pressures, and full duplex ultrasound mapping of bilateral upper extremity arteries and veins. A blood pressure differential of greater than 20 mmHg, an asymmetric pulse exam, unexpectedly weak pulses at any level in the arm, or findings on duplex ultrasound of significant arterial stenosis proximal to the proposed AV access mandate additional vascular imaging. In addition, a modified Allen's test can be performed to evaluate the status of the palmar arch, although the significance of a positive or negative test result in the planning of hemodialysis AV access is controversial.

Although preoperative photoplethysmography (PPG) is not routinely performed, it can be helpful in the evaluation of symptomatic patients with arterial insufficiency and helps guide AV access placement to avoid ischemic complications.

Avoiding brachial artery inflow — Perhaps the most important strategy available to reduce the risk of ischemia is to minimize the use of the brachial artery for inflow for hemodialysis AV access. Distal AV fistulas created at the wrist using radial artery inflow have an extremely low incidence of HAIDI. Unfortunately, unfavorable venous anatomy and circumferential radial artery calcification often seen in patients with diabetes may preclude the creation of distal radiocephalic AV fistula. An alternative method uses the proximal radial artery (figure 1), rather than the brachial artery for inflow when more distal arterial inflow is not feasible [14]. The brachial artery bifurcation and proximal radial artery can be easily identified by preoperative duplex ultrasound, and AV fistulas can be performed in the cephalic, basilic, or median antecubital vein with excellent functional patency and a low risk of ischemia. In a series of 1396 proximal radial artery AV fistulas, DASS requiring intervention occurred in only 39 (2.8 percent) [15].

Another option that has been proposed is the primary use of proximal arterial inflow to possibly mitigate the risk of set [14]. This strategy of proximalization of arterial inflow (PAI) has been successfully used to treat DASS when it occurs, and strategies to preemptively create autogenous AV access using axillary artery inflow have been successful for preventing DASS in selected high-risk patients [16]. (See 'Proximalization of arterial inflow' below.)

Limiting proximal arterial inflow — If arterial inflow must originate from arteries proximal to the radial artery, in particular proximal to the brachial bifurcation, limiting the inflow may provide an advantage.

Limiting the length of the arteriotomy to a maximum of 4 to 6 mm may be particularly important in patients with diabetes or peripheral artery disease. In addition, use of continuous suture may prevent future increases in the anastomotic surface area and prevent late development of DASS [17]. Whether the configuration of the anastomosis impacts the incidence of DASS was evaluated in a meta-analysis that included 301 AV fistulas [18]. The risk of developing DASS was significantly lower for an end-to-side anastomosis compared with side-to-side anastomosis with no effect on maturation or patency.

When an AV graft is selected for hemodialysis AV access, tapered polytetrafluoroethylene grafts for hemodialysis AV access have the theoretic advantage of limiting volume flow and reducing the incidence of DASS compared with straight 6 mm AV grafts. However, randomized trials have produced equivocal results regarding the value of tapered AV grafts. One trial suggested that AV graft flow and rates of thrombosis and ischemia were similar for straight 6 mm compared with 4 to 7 mm tapered AV grafts placed in a forearm loop configuration [19]. Another trial randomly assigned patients without diabetes to 6 mm straight AV grafts or 6 to 8 mm tapered AV grafts in a brachial axillary position and reported improved primary and primary assisted patency rates for the tapered AV grafts but similar secondary patency [20]. The complication rate was 0.45 episodes per graft-year for 6 mm AV grafts, and 0.19 episodes per graft-year for the 6 to 8 mm AV grafts. Although five patients in the 6 mm group and seven patients in the tapered group had transient pallor or coolness of the hand, no patient in either group developed clinical steal requiring intervention. In a later review of 3608 upper extremity AV grafts reported from the Vascular Quality Initiative, patency rates and the incidence of DASS were no different for tapered compared with straight AV grafts [21]. Regardless of the equivocal clinical evidence supporting their use, tapered AV grafts continue to be widely used in clinical practice.

Limiting venous outflow — The antecubital fossa has a wide range of options for venous outflow. Limiting outflow to superficial and accessible veins can further reduce the risk of ischemia and improve AV fistula maturation rates. The importance of ligating the perforating venous branch, which is consistently present and joins the brachial vein, has been emphasized [22]. This branch can be used for the AV fistula anastomosis but otherwise should be ligated to improve superficial venous flow and AV fistula maturation and also reduce the risk of steal. Significantly improved radial artery pressure has been demonstrated after ligation of the deep perforating vein, suggesting that a considerable amount of flow from the AV fistula was diverted into the deep venous system [22]. In addition, careful attention to the antecubital venous anatomy will maximize functional patency of the AV fistula and minimize ischemic complications. AV fistula outflow into both the basilic and cephalic veins may be advantageous in situations where marginal veins are used and maturation is unpredictable. However, there may be also a potential disadvantage to preserving unnecessary venous collaterals or outflow veins in the risk of developing DASS [23]. How these factors will be influenced by new percutaneous AV fistula creation techniques, which often result in deep and superficial venous outflow, remains to be seen.

CLINICAL MANIFESTATIONS — After the creation of an arteriovenous (AV) fistula, it is critical that every patient have verbal and written instructions describing the symptoms associated with hemodialysis access-induced distal ischemia (HAIDI) including dialysis access steal syndrome (DASS) and ischemic monomelic neuropathy (IMN). The patient should be instructed to contact their surgeon or another health care provider immediately if the symptoms described below occur since permanent injury (eg, nerve damage) can result from delays in care.

Dialysis access steal syndrome — Presenting symptoms and signs of DASS are those of upper extremity ischemia such as hand pain, coldness, diminished sensation or motor function, cyanosis or pallor of the digits, and diminished or absent pulses. Less severe symptoms and signs, such as paresthesias and a sense of coolness with retained pulses, are more common. Severe ischemic symptoms, characterized by loss of sensation or weakness, may be more common among patients with diabetes and in those of advanced age [24,25]. Symptoms often worsen during hemodialysis sessions. Symptoms may improve with compression of the AV access. (See 'Diagnosis' below and "Overview of upper extremity ischemia".)

In a review that included 21 studies reporting on surgically or percutaneously treated patients with DASS, symptoms were classified as "acute" (<24 hours after AV access construction), "subacute" (within one month), or "chronic" (after one month) [26]. The occurrence of acute DASS correlated strongly (88 percent) with nonautogenous AV access (ie, AV graft), and chronic DASS was predominantly (91 percent) observed following autogenous AV access (ie, AV fistula) usually based on brachial artery inflow.

Ischemic monomelic neuropathy — IMN is a rare variant of HAIDI that likely is within the spectrum of ischemic steal, but it has distinct characteristics from the typical presentation [27]. IMN is caused by focal nerve ischemia and generally results from sudden diversion of the blood supply away from the nerves of the forearm and hand. The condition is uncommon, and the true incidence is unknown, but IMN almost universally occurs with brachial artery-based AV access procedures and predominates in females and patients with diabetes. Dysfunction of multiple upper extremity peripheral nerves occurs [28].

Symptom onset is usually immediately after AV access placement, and neurologic symptoms predominate, often in the absence of tissue ischemia of the hand. IMN presents as diffuse sensory and motor deficits in the radial, ulnar, or median nerve distributions. Presenting symptoms include pain, paresthesias, and numbness in the hand. Significant motor dysfunction is also present, and deficits include poor wrist extension, poor function of the intrinsic hand musculature, and poor thumb opposition. These deficits can progress to a typical claw hand deformity (picture 1). Typically, the hand is warm, capillary refill is preserved, and a palpable radial or ulnar pulse or audible Doppler signal is present. The absence of tissue ischemia is in distinct contrast to the clinical presentation of typical DASS.

CLINICAL STAGING — Multiple authors have attempted to grade or stage the severity of hemodialysis access-induced distal ischemia (HAIDI) [29,30]. Staging is generally based on the clinical presentation and is correlated with the need for intervention. An individualized approach to treatment based on clinical staging is presented below. (See 'Individualized approach to HAIDI' below.)

An early classification described ischemia as mild (stage 1), moderate (stage 2), or severe (stage 3) [30]. A later classification provided a more detailed four-stage classification, which is shown in the table (table 1) [29].

DIAGNOSIS — The diagnosis is predominantly clinical based on history and physical examination findings of upper extremity ischemia in a patient with an arteriovenous (AV) access. Physical examination can confirm a diagnosis of vascular steal by manually compressing the AV access and noting an improvement in the patient's symptoms. However, physical examination alone may not be accurate in identifying the anatomic cause of the vascular steal [31]. Thus, among patients presenting with symptoms of extremity ischemia, there is a low threshold to obtain noninvasive vascular evaluation. The diagnosis can be confirmed using noninvasive vascular testing. Physiologic tests such as digital waveforms and pressures, with and without AV fistula compression, are sensitive for a diagnosis of steal. Duplex ultrasound may identify the presence of arterial stenosis and/or flow reversal and can quantify flow [32-34]. For patients suspected of having a proximal lesion, and for whom treatment is being considered, upper extremity arteriography may be appropriate. (See 'Noninvasive vascular studies' below.)

Differentiating IMN from DASS — Recognition of ischemic monomelic neuropathy (IMN) may be problematic because of its infrequent occurrence and absence of significant tissue ischemia in the involved extremity. The presence of severe hand pain but absence of significant tissue ischemia with the presence of a radial artery pulse or Doppler signal and preserved digital blood flow differentiates IMN from dialysis access steal syndrome (DASS) [35]. Electromyography performed on patients with IMN may demonstrate signs of acute denervation.

The following features help distinguish IMN from DASS [25]:

Immediate onset for IMN versus insidious for DASS.

Females and patient with diabetes predominate for IMN, whereas the sex distribution is variable for DASS.

For IMN, brachial-based AV access is predominantly affected. For DASS, AV access at any level can be affected.

Only nerve tissue is affected with IMN, and the level of nerve ischemia is severe (picture 1). For DASS, tissue ischemia can range from mild to severe and affects the skin more than the muscles and more than the nerves.

The radial pulse should be present in IMN and is weak or absent with DASS. The digital pressures follow this pattern (ie, normal or slightly decreased with IMN, but markedly decreased with DASS).

Differential diagnosis — The differential diagnosis includes any of the other causes of upper extremity ischemia, including, but not limited to, atherosclerotic disease, embolism, traumatic (including iatrogenic) injury, arterial dissection, and arteritis. (See "Overview of upper extremity ischemia", section on 'Incidence and etiologies'.)

The differential diagnosis of extremity hand pain or hand dysfunction temporally related to surgery for the creation of the hemodialysis AV access includes incisional pain, surgical site infection, hematoma, complications of anesthesia, peripheral nerve compression, and carpal tunnel syndrome.

Noninvasive vascular studies — To confirm the diagnosis and assess the severity of ischemia, noninvasive vascular testing using digital photoplethysmography tracings (ie, PPGs) and pressure measurements, and duplex ultrasound to assess flow direction and volume flow, are useful tools.

Digital studies with arteriovenous access compression — Evaluation of digital pressure measurement as well as the amplitude of PPGs at rest and with AV access compression (waveform 1) can help confirm a diagnosis of hemodialysis access-induced distal ischemia (HAIDI). In a study that measured arterial pressure in the third finger ipsilateral to the AV access in 40 patients with clinical ischemia and 25 patients without ischemia, the mean digital pressure was significantly lower in patients with HAIDI (30 versus 102 mmHg), as was the mean digital brachial index (DBI) value (0.3 versus 0.8) [36]. The change in digital pressure with AV access compression was also significantly lower in patients with HAIDI. The authors established that a digital pressure <60 mmHg or a DBI <0.4 in a patient with an AV access was highly associated with hand ischemia. In addition to aiding diagnosis, a lack of improvement in hemodynamics with compression of the AV fistula may help to identify patients who will not benefit from an intervention that specifically targets the existing AV access.

Duplex ultrasound — Duplex ultrasound is another important tool in the evaluation of HAIDI. However, while identification of flow reversal in the artery distal to the AV access is helpful in the diagnosis, it does not necessarily correlate with clinical symptoms or dictate the need for intervention.

Quantifying arteriovenous access flow — Measurement of volume flow is not helpful for establishing a diagnosis of HAIDI, but it is critical in planning treatment in symptomatic patients. (See 'Individualized approach to HAIDI' below and 'High-flow arteriovenous fistulas' below.)

Measurement of volume flow (expressed in mL/min) in the AV access can be accomplished using ultrasound measurements of vessel diameter combined with Doppler-derived velocity determinations [37]. Alternatively, one of the dilution methods can be used. (See "Clinical monitoring and surveillance of the mature hemodialysis arteriovenous fistula", section on 'Intra-access flow rate' and "Clinical monitoring and surveillance of hemodialysis arteriovenous grafts to prevent thrombosis", section on 'Intra-access blood flow monitoring'.)

AV access flow can be arbitrarily defined as low (<600 mL/min), normal (600 to 1500 mL/min), and high (>1500 mL/min) [38]. Ideal AV access flow is the minimal flow that is adequate to prevent thrombosis but provides adequate hemodialysis. Complications such as HAIDI and aneurysmal AV fistula degeneration (picture 2) can occur with high- or low- flow AV access. Similarly, cardiac dysfunction, congestive heart failure, and pulmonary hypertension can occur with low- or normal-flow AV access but can be exacerbated by high-flow fistulas, which can significantly increase cardiac output. (See 'High-flow arteriovenous fistulas' below.)

APPROACH TO MANAGEMENT

Individualized approach to HAIDI — Treatment of hemodialysis access-induced distal ischemia (HAIDI) should be individualized and is based upon the clinical stage and severity of ischemia, type and location of arteriovenous (AV) access, and its volume flow [5,24,29,39].

The clinical features and staging are presented above (table 1). (See 'Clinical staging' above.)

The treatment of HAIDI based on staging is as follows (algorithm 1):

Stage I/IIa – Does not require intervention and should be managed conservatively with close observation of symptoms.

Stage IIb/III/IVa requires intervention, the nature of which is based on AV access volume flow. (See 'Treatment options' below.)

Stage IVb – The limb is managed expectantly; amputation is frequently necessary. (See "Upper extremity amputation", section on 'Digit and thumb amputation'.)

For patients who do not require intervention but have mild symptoms, medications should be optimized to stabilize blood pressure and prevent hypotension (particularly important while on hemodialysis), and a warming glove can be used. Vigilant follow-up and patient instruction to avoid injury to the hand and to call for worsening symptoms are essential.

AV access ligation would effectively reverse ischemic symptoms in most cases, but preservation of the AV access, if possible, should be an equally important goal. The importance of determining AV access volume flow has been emphasized; treatment differs for high-flow versus normal- or low-flow dialysis access steal syndrome (DASS) [29]. Using an algorithm, such as one based on AV access flow (algorithm 1), is helpful for determining the best treatment in these challenging patients. (See 'Quantifying arteriovenous access flow' above.)

Flow-dependent treatment can be summarized as follows:

A high-flow AV access (>1500 mL/min) may require only flow reduction. (See 'Precision banding' below.)

A low- or normal-flow AV access (≤1500 mL/min) will require a revascularization procedure to alter flow hemodynamics of the AV access to improve distal perfusion while maintaining AV access function. (See 'Revascularization procedures' below.)

Arteriovenous access ligation for IMN — We agree with the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Vascular Access: 2019 Update, and the Society for Vascular Surgery Clinical Practice Guidelines for the Surgical Placement and Maintenance of Arteriovenous Hemodialysis Access, that recommend immediate AV access closure when ischemic monomelic neuropathy (IMN) is diagnosed [24]. This results in loss of AV access and the need to search for alternative sites with the same potential risks. (See 'Arteriovenous access ligation' below.)

These recommendations are based on limited data as large series of patients with IMN are lacking in the literature. Until more effective strategies can be developed to prevent or manage IMN, it seems reasonable to recommend AV access closure in patients with available alternative AV access sites. Despite these recommendations, recovery from this condition is at best unpredictable. Even with timely diagnosis and appropriate intervention, patients may have persistent and significant clinical deficits [27,35,40]. In separate reviews, the majority of patients with IMN were treated with ligation of the AV access, but the results of treatment were variable, with the majority of patients demonstrating only partial clinical recovery [35,40]. The level of improvement after treatment may be related to the duration of ischemia.

High-flow arteriovenous fistulas — A high-flow AV fistula is defined as one that has a volume flow >1500 mL/min [38]. High-flow hemodialysis AV access can produce symptoms of DASS but can also be asymptomatic. (See "High-flow hemodialysis arteriovenous access".)

High-flow AV fistulas also have the potential to cause numerous AV access-related and cardiovascular complications. These complications are listed below and reviewed separately.

Aneurysmal enlargement of the AV access (see "Arteriovenous fistula creation for hemodialysis and its complications", section on 'Aneurysm/pseudoaneurysm/megafistula')

Accelerated central venous stenosis (see "Central vein obstruction associated with upper extremity hemodialysis access")

Pulmonary hypertension (see "Pulmonary hypertension in patients with end-stage kidney disease")

Cardiac overload and cardiopulmonary recirculation (see "Evaluation and management of heart failure caused by hemodialysis arteriovenous access")

Functional outflow obstruction (eg, cephalic arch stenosis) (see "Failure of the mature hemodialysis arteriovenous fistula", section on 'Stenotic vascular lesions')

Inflow/outflow mismatch can occur in the presence of cephalic arch stenosis or central venous occlusion and can lead to significant arm swelling and the development of chest wall collateral veins. When central venous occlusion persists in spite of attempted interventions, flow reduction in the AV fistula may improve arm swelling. In one small review, the Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) banding procedure reduced AV access flow in 22 patients with central venous occlusion with improvement or resolution of swelling in all cases [41]. (See 'Precision banding' below.)

Cardiac decompensation is a significant concern in the end-stage kidney disease population, particularly with the potential of the AV access to produce structural and functional cardiac changes as a result of the increased cardiac output [42]. High-output cardiac failure is a combination of clinical findings of systemic venous or pulmonary congestion and a resting cardiac output of greater than 8 L/min. Management focuses on medical treatment to reduce volume excess and reduction of AV access flow. Flow reduction in patients with high-flow AV fistulas improves cardiovascular performance and decreases need for hospitalization for acute heart failure [43]. In patients with cardiac overload and steal symptoms, flow reduction can be accomplished by minimally invasive techniques such as the MILLER banding technique or by open surgical plication or banding of the AV access with excellent outcomes [44]. Other techniques (eg, proximal radial artery ligation [PRAL], revision using distal inflow [RUDI]) for AV access flow reduction have also been used for cardiac failure [45]. AV access ligation remains an option if severe heart failure persists after efforts at flow reduction have failed. Controversy exists over the decision to ligate a functioning AV access after successful renal transplant to prevent long-term cardiac decompensation [43]. (See 'Precision banding' below and 'Revascularization procedures' below.)

TREATMENT OPTIONS — Severe or persistent ischemic symptoms warrant treatment to prevent the development of permanent injury (algorithm 1). (See 'Individualized approach to HAIDI' above.)

For patients with inflow arterial stenosis or progressive arterial occlusive disease in the extremity proximal to the arteriovenous (AV) anastomosis, percutaneous catheter-based arterial intervention may benefit the patient. (See 'Treatment of inflow stenosis' below.)

For patients with a distal radial AV fistula, occlusion of the artery distal to the anastomosis eliminates reversal of flow without jeopardizing the extremity or the AV access provided the ulnar artery is patent. (See 'Distal artery occlusion' below.)

For patients with a high-flow AV fistula, flow reduction using precision banding (eg, open or minimally invasive limited ligation endoluminal-assisted revision [MILLER] procedure) can be performed. (See 'Precision banding' below.)

For patients in whom preservation of the AV fistula is a high priority, revascularization procedures specifically designed to improve distal flow (figure 2) include the distal revascularization interval ligation (DRIL) procedure, proximalization of arterial inflow (PAI), and revision using distal inflow (RUDI). (See 'Revascularization procedures' below.)

For patients with ischemic symptoms that are very severe or in whom revascularization is not possible (eg, ischemic monomelic neuropathy [IMN]), the AV access will require ligation. (See 'Arteriovenous access ligation' below.)

The theoretical effects of several potential AV access modifications used to mitigate ischemia have been analyzed [46]. An extended axillobrachial bypass (distal revascularization part of the DRIL) increased forearm blood flow by a factor of 1.2 to 12.1, and ligating the intervening vessel (conversion to DRIL) increased the forearm flow by an additional factor of only 1.4 to 1.9. Moving the arterial anastomosis to a more proximal site increased forearm blood flow by increasing pressure at the split point between the distal circulation and the hemodialysis AV access and also initiated collateral flow at a higher point in the arm, which was advantageous for preventing or treating ischemic symptoms in the hand.

It is important to note the medicolegal implications of hemodialysis access-induced distal ischemia (HAIDI) including dialysis access steal syndrome (DASS) and IMN. Clinical decision making may be challenging, and appropriate documentation of treatment options and potential consequences is important. (See "Malpractice risk associated with surgical procedures".)

Treatment of inflow stenosis — Although proximal arterial disease as a cause of HAIDI is uncommon, it can be identified by simple techniques such as pulse examination, differential blood pressure measurements, duplex ultrasound, or angiography. Treatment of the inflow stenosis in patients with ischemia may be curative or serve as an adjunct to other treatments.

In a review of 52 patients with severe HAIDI requiring intervention, significant subclavian or brachial artery stenosis was found in nearly one third of the patients [13]. A review of upper extremity endovascular interventions for symptomatic HAIDI reported a high success rate for interventions performed for atherosclerotic disease [47]. Clinical outcomes were worse for patients with disease below the elbow. Such findings underscore the importance of preoperative vascular assessment. (See 'Identifying correctable arterial lesions' above and "Patient evaluation prior to placement of hemodialysis arteriovenous access", section on 'Arterial evaluation'.)

Distal artery occlusion — Although HAIDI is rare with radiocephalic AV fistulas, occlusion of the distal artery, which eliminates flow reversal, is an option unique to this site. Distal radial artery occlusion can be accomplished by embolization or with open surgical ligation [48].

Occlusion of the distal artery eliminates reversal of flow without jeopardizing the extremity or the AV access provided the ulnar artery is patent. Duplex ultrasound confirmation of flow reversal in the distal radial artery and ulnar artery patency is critical before this procedure is undertaken. In addition, improvement in digital waveforms should be demonstrated by compressing the AV access or the radial artery distal to the AV fistula.

Precision banding — For high-flow AV fistulas, banding may be effective for treating DASS and also for reducing potentially life-threatening cardiopulmonary complications and other problems associated with pathologic increases in cardiac output. (See 'High-flow arteriovenous fistulas' above.)

Banding can be accomplished using a variety of catheter-based or open surgical techniques. Precision banding implies that the procedure is done in conjunction with accurate measurements of the degree of flow reduction [49].

Open surgical banding can be performed with plication, interposition of a narrow segment of conduit, or placement of a cuff or suture over an intraluminal balloon or dilator to achieve precise results [50]. A minimally invasive method for performing precision banding, the Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) procedure, has reported excellent results [44,51]. Another technique has described banding between puncture sites in low-flow AV fistulas to maintain a pressure gradient between the arterial and venous puncture sites that would not be possible with traditional banding at the arterial anastomosis [52]. Novel endovascular approaches to flow reduction using stent-grafts have also been proposed [53,54].

Outcomes of banding can be assessed by measuring digital pressures or digital brachial index or with photoplethysmography, pulse volume recording (PVR) waveforms, or duplex ultrasound-derived volume flow measurements. In a small study of five patients with DASS, resolution of ischemic symptoms with AV access banding occurred in all patients with intraoperative increase of 5 mm in the PVR waveforms [55]. In addition, intraoperative measurement of volume flow after banding can confirm reduction of high flow. In a one-year follow-up study after surgical banding of high-flow AV accesses, 52 percent of patients developed recurrent high flow (>2 L/min) [56]. Risk factors for recurrent high flow in banded brachial artery-based AV accesses were immediate postbanding AV access flow of >1 L/min and young age (<45 years).

Revascularization procedures — For low- or normal-flow AV access associated with HAIDI, revascularization options include DRIL or PAI (figure 2). DRIL is an effective technique for the treatment of vascular access-induced ischemia with adequate long-term outcomes. For high-flow AV fistulas, RUDI can be used. RUDI revises high-flow fistulas, and effectively changes the flow dynamics in the arm after the procedure [57].

The arterial ligation required in the DRIL procedure theoretically puts the extremity at risk if the bypass fails, whereas both the RUDI and PAI procedures, which do not include arterial ligation, put the AV access rather than the extremity at risk in case of bypass failure.

There are few direct comparisons between the various procedures.

One retrospective review compared DRIL with RUDI for the treatment of ischemic symptoms in 58 patients [58]. The main indication for intervention was tissue loss, which occurred in 61 percent; the remainder had ischemic rest pain. There were no significant differences in primary patency, cumulative secondary patency, survival at one and three years, or resolution or improvement in pain/healing of ischemic ulcers or amputations.

A large retrospective series looked at 22 studies (459 individuals) who were underwent DRIL [5]. The time to ischemia was 196 days (interquartile range 30 to 600 days). Ischemia grade 3 and 4 was the most common presentation occurring in 52 percent. The overall success (grades 1 to 4) was 81 percent (95% CI, 80.9-82.5) during a mean follow-up of 22.2 months. The conduit of choice was the great saphenous vein (65 percent), and bypass thrombosis was highest in the polytetrafluoroethylene group (19 of 44, 43 percent).

Revision using distal inflow — In patients with HAIDI requiring flow reduction, the RUDI procedure (figure 2) has been an effective strategy. In this procedure, the AV fistula is ligated at its origin and a vein or prosthetic conduit is used to establish inflow from a more distal arterial source, usually proximal to mid radial artery. By using a smaller distal artery as inflow, resistance is added to the system and the AV fistula is lengthened with a small-diameter bypass. In small series, RUDI has been successful in reducing flow in high-flow AV fistulas and relieving symptoms of DASS [58-61].

Distal revascularization interval ligation — Originally described in 1988, the DRIL procedure (figure 2) has been successful in reliably restoring antegrade flow to the ischemic limb by eliminating the potential physiologic pathway for DASS [62]. The procedure combines performance of a bypass from above the arterial anastomosis of the AV fistula to a distal vessel, and ligation of the artery distal to the original AV fistula anastomosis to prevent reversal of flow. The ligation and bypass procedures are performed at a single surgery [63,64].

Several studies have confirmed both excellent bypass patency rates and the effectiveness of the DRIL procedure in relieving symptoms of DASS [5,62,65-68]. Although the DRIL procedure has proven efficacy in the treatment of steal, concerns remain about arterial ligation and reliance on the conduit used for distal revascularization [68-70]. There may be an understandable reluctance to ligate a normal artery, making alternative treatment options, such as PAI, attractive. (See 'Proximalization of arterial inflow' below.)

Proximalization of arterial inflow — The PAI procedure (figure 2) is intended to move the inflow for the AV access to a more proximal arterial level, specifically the axillary or proximal brachial artery [71]. Zanow, who originally described this technique, experimentally demonstrated the hemodynamic advantages and improvement in distal perfusion of a more centrally located AV anastomosis [28]. To perform PAI, a conduit of vein or polytetrafluoroethylene is used as an interposition graft from the axillary or proximal brachial artery to the AV fistula or AV graft above the previous brachial artery anastomosis, and the access is ligated at the previous anastomosis.

PAI has been effective in treating HAIDI without the need to perform arterial ligation, although caution is advised in using this procedure in the presence of extensive tissue loss where access ligation may be a better option (waveform 1) [72].

Arteriovenous access ligation — Although it is important to make every possible effort to preserve a functioning hemodialysis AV access, there are situations in which ligation of the AV access may be an appropriate choice. Severe functional impairment or impending or frank tissue necrosis that cannot be treated with preservation of the AV access mandates abandonment of the AV access. Severe complications in the immediate postoperative period (eg, bleeding, intractable steal) may also indicate AV access ligation. Any unused or unusable AV fistula that is causing steal should be carefully evaluated for ligation. IMN is also an indication for ligation of the AV access, acknowledging that improvement in symptoms is unpredictable.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis" and "Society guideline links: Hemodialysis vascular access" and "Society guideline links: Acute extremity ischemia".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Chronic kidney disease (The Basics)" and "Patient education: Dialysis and diet (The Basics)")

Beyond the Basics topics (see "Patient education: Chronic kidney disease (Beyond the Basics)" and "Patient education: Hemodialysis (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Ischemic complications – Hemodialysis access-induced distal ischemia (HAIDI) including dialysis access steal syndrome (DASS) and ischemic monomelic neuropathy (IMN) occur for a variety of reasons that almost always include decreased blood flow to the distal extremity resulting from increased blood flow through the AV access. The incidence and timing vary with the type and location of the AV access. (See 'Introduction' above and 'Incidence, risk factors, and prevention' above.)

Risk factors – Identifying patients with risk factors is important so that preemptive measures to reduce the risk of ischemic complications can be implemented. Risk factors include brachial artery inflow, female sex, diabetes, atherosclerotic vascular disease (coronary heart disease, peripheral artery disease), and advanced age. (See 'Risk factors' above.)

Risk reduction – Although it is not possible to predict for certain the development of ischemic complications in individual patients, steps can be taken to minimize the risk. These include preemptive identification of proximal arterial disease and avoiding the brachial artery as an inflow vessel and, if using the brachial artery cannot be avoided, limiting the length of the arteriotomy to reduce inflow. (See 'Strategies for prevention' above.)

Clinical manifestations and diagnosis

DASS – DASS presents with typical clinical features of upper extremity ischemia (hand pain, coolness, diminished sensory/motor function) and can occur in high- or low-volume-flow AV accesses. The diagnosis of DASS is predominantly clinical based on history and physical examination and by noting an improvement in the patient's symptoms with manual compression of the AV access. The diagnosis can be confirmed using noninvasive vascular testing. For patients in whom a proximal lesion is suspected, upper extremity arteriography is appropriate. (See 'Diagnosis' above.)

IMN – IMN is a very rare variant that presents with severe hand pain. Differentiating IMN from DASS is important to implement appropriate treatment to preserve hand function. (See 'Clinical manifestations' above and 'Differentiating IMN from DASS' above and 'Arteriovenous access ligation for IMN' above.)

Staging of ischemia and management – Staging is generally based on the clinical presentation (table 1) and correlates with the need for intervention. Surgical treatment should focus on preservation of a functional AV access while alleviating ischemic symptoms. Treatment options include AV access ligation for severe ischemia, banding procedures to reduce flow in the high-flow AV access, or procedures to improve distal blood flow in the low- or normal-flow AV access (algorithm 1). (See 'Approach to management' above and 'Treatment options' above and 'Clinical staging' above.)

Minimal ischemia – Patients with minimal ischemia (stage I and IIa) do not require intervention and should be managed conservatively with close observation of symptoms. (See 'Individualized approach to HAIDI' above.)

Reversible ischemia – Patients with intolerable but reversible ischemia (stage IIb, III, and IVa) require intervention, the nature of which is based on the volume flow rate of the AV access. Proximal artery inflow lesions should be addressed prior to interventions involving the AV access.(See 'Quantifying arteriovenous access flow' above and 'Treatment of inflow stenosis' above.)

-A high-flow AV access (>1500 mL/min) may require only flow reduction, which is accomplished with precision banding (minimally invasive or open surgical techniques) in concert with duplex ultrasound assessment of AV access flow. Another option is the Revision Using Distal Inflow (RUDI) procedure. (See 'Precision banding' above and 'Revision using distal inflow' above.)

-A low- or normal-flow AV access (≤1500 mL/min) will require revascularization to increase distal perfusion to improve ischemia and maintain AV access function. Options include the distal revascularization interval ligation (DRIL) or proximalization of arterial inflow (PAI) procedures. Specifically for the wrist AV fistula, ligation of the distal radial artery alone may improve flow through the AV access. (See 'Distal revascularization interval ligation' above and 'Distal artery occlusion' above and 'Proximalization of arterial inflow' above.)

Irreversible ischemia – Patients with extensive tissue loss and significant functional deficits have irreversible ischemia (Stage IVb). The limb is managed expectantly; amputation is frequently necessary. (See "Upper extremity amputation".)

Management of IMN – For IMN, we agree with guidelines that recommend immediate AV access closure. Unfortunately, even with timely ligation of the AV access, most patients with IMN demonstrate only partial clinical recovery. (See 'Arteriovenous access ligation for IMN' above.)

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Topic 113760 Version 17.0

References

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