Vascular insufficiency from AV fistula

Background

  • Steal syndrome = Distal hypoperfusion ischemic syndrome[1]
  • Higher risk with more proximal fistulas[2]
    • 10–25% of brachiocephalic and basilic artery fistulas
    • 4.3–6% of forearm prosthetic implants
    • 1–1.8% of radiocephalic fistulas
  • Classically elderly woman with DM
  • Patietn history may include revascularization or banding efforts that re-stenose

Clinical Features

  • Distal extremity becomes ischemic due shunting of arterial blood to venous side
    • Exercise pain, nonhealing ulcers, cool, pulseless digits
  • 4 Stages
    • Stage I: pale/blue and/or cold hand without pain
    • Stage II: pain during exercise and/or hemodialysis
    • Stage III: rest pain
    • Stage IV: ulcers/necrosis/gangrene

Differential Diagnosis

AV Fistula Complications

Evaluation

  • Initial diagnosis is clinical
  • Confirmation by[3]:
    • Digital blood pressure measurement
    • Duplex ultrasonography
    • Transcutaneous PO2 measurement

Management

  • Percutaneous transluminal angioplasty (PTA)
  • Surgery

Disposition

  • Admit

See Also

External Links

References

  1. *Malik et Al. Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies. J Vasc Access. 2008 Jul-Sep;9(3):155-66.
  2. Tordoir JHM, et al. Upper extremity ischemia and hemodialysis vascular access. European journal of vascular and endovascular surgery. 2004. 27(1):1-5.
  3. Rutherford RB. The value of noninvasive testing before and after hemodialysis access in the prevention and management of complications. Semin Vasc Surg. 1997; 10:157–161.