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Management of steal syndrome || Dr Ravi Bansal

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Management of steal syndrome. Dr Ravi Bansal

Management of steal syndrome. Dr Ravi Bansal

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  • 1. Dr Ravi Bansal MD, DM Nephrology(AIIMS) Consultant Nephrologist Pushpawati Singhania Research Institute New Delhi
  • 2. Steal syndrome-Definition Clinical condition caused by arterial insufficiency distal to a hemodialysis AV access. Usually associated with reversal of distal flow  Also called - Digital hypoperfusion ischemic syndrome (DHIS) Severe ischemia: Radial AV Fistula 1% Brachial AV Fistula or Graft 3-6%
  • 3. Classification of steal syndrome Stage I Retrograde diastolic flow without complaints; steal phenomenon Stage II Pain on exertion and/or during haemodialysis Stage III Rest pain Stage IV Ulceration/necrosis/gangrene Eur J Vasc Endovasc Surg 2004; 27: 1–5
  • 4. Etiology True Steal from the Forearm Arteries Can be clinically silent retrograde flow. Presence of Occlusive Arterial Stenoses significant (50%) arterial stenoses commonly seen in patients of hand ischemia. Incidence 62 to 100% by arteriography. Distal Arteriopathy Vascular calcification and diabetes
  • 5. Assessment Risk factors: Diabetes, PVD, Age , Brachial artery fistula. Dopplar ultrasound: with access compressed, the post- stenotic flow pattern permits the localization of a potential stenosis Wrist or digital arterial pressures: below 50 mmHg Digital(wrist)/brachial pressure DBI <0.6 Pulse oxymetry: O2 Sat <90%, Arteriography J Am Coll Surg 2000; 191: 301–310 Schanzer A et al.: Vascular Medicine 2006; 11:1-5
  • 6. Clinical spectrum Hand Pain Numbness ( Diminished altered sensation) Pale , cold hand Diminished or absent pulses Poor capillary filling Severe neuropathy (Ischemic Monomelic Neuropathy) Atrophy, weakness Loss of function Gangrene
  • 7. Psri data 123 patients screened and data collected: For DM, CAD, Duration of AVFistula, location of fistula, duration on HD, s/s to suggest ischemia Hand Pain 68 diabetics, 35 CAD, avf (1 month to 8 yrs), 38% brachial Ischemic s/s in 8 patients. One patient with severe ischemic changes.
  • 8. Treatment Goal Reversing the Ischemia Preserving the Access
  • 9. Prevention Pre –op assessment History of DM, PVD Exam: Pulses, Bilateral BP, Allen’s Test, Doppler Additional Studies: Plethysmography/digital pressures, flow, pulse oximetry, arteriography. Intra-op Location and size of anastomosis In high risk patients- intraop flow measurement, digital pressures, pulse-oximetry
  • 10. Treatment options Percutaneous interventions percutaneous balloon angioplasty intravascular stent insertion intravascular coil insertion MILLER procedure - minimally invasive limited ligation endoluminal-assisted revision Surgical interventions banding procedure ligation procedure tapered graft insertion PAI (Proximalization of the Arterial Inflow) DRIL- distal revascularization-interval ligation RUDI - revision using distal inflow
  • 11. Classification of AV Fistula Depending on the flow values measured, (i) ‘high flow’ (>800 ml/min in native fistulae, >1200 ml/min in access grafts), (ii) ‘normal flow’ and (iii) ‘low flow associated steal’ (<400 ml/min in native fistulae, <600 ml/min in access grafts) can be distinguished
  • 12. Percutaneous Balloon Angioplasty Detection of proximal arterial stenosis Study of the arterial anatomy distal to AV access, for planning corrective procedure
  • 13. Intravascular stent insertion
  • 14. Treatment of steal syndrome in a distal radiocephalic arteriovenous fistula using intravascular coil embolization JOURNAL OF VASCULAR SURGERY 2008 , 47(2), 457-9
  • 15. ligation procedure Access ligation will lead to an immediate improvement of steal syndrome and also to the loss of the access with the need to create another one, again running the risk of provoking a steal syndrome. in severe ischaemia or IMN
  • 16. Banding Procedure Banding aims at a reduction of access flow for high flow associated steal syndrome. when the degree of banding is controlled by intraoperative flow measurements (aiming at 400∼ ml/min in native fistulae and 600 ml/min in access∼ grafts)
  • 17. Banding Banding a low flow access to a degree where steal syndrome disappears will result in inefficient dialysis or even access thrombosis
  • 18. • excision of a portion of the vein and plication with mattress or continuous sutures • crossed PTFE band • interposition of a 4 mm PTFE
  • 19. MILLER procedure - minimally invasive limited ligation endoluminal-assisted revision Performed banding by tying a non-resorbable suture around the access over an inflated 4 or 5 mm dilatation balloon under fluoroscopic control to gain a defined reduction in the vessel diameter only in high flow associated steal
  • 20. PAI (Proximalization of the Arterial Inflow) Enhances access flow Therefore in low flow associated steal syndrome Zanow J, et al. J Vasc Surg 2006, 43:1216-1221 n=34 Complete symptom relief=84% Secondary patency (1year)=90%
  • 21. DRIL- distal revascularization-interval ligation DRIL is a complex and time-consuming procedure, possible only when a suitable vein can be harvested. Can decrease flow by 25% >5 cm distance between the proximal bypass anastomosis and the access anastomosis prevent retrograde diastolic flow in the graft
  • 22. DRIL in AV Graft
  • 23. RUDI - revision using distal inflow In patients with high flow induced cardiac failure due to a brachial AV access, closing the anastomosis in the antecubital fossa and interposing a graft between the forearm ulnar or radial artery has been shown to effectively reduce access flow by more than 50%
  • 24. Treatment strategies of arterial steal after arteriovenous access. Gupta N et al METHODS: Patients with ISS between June 2003 and June of 2008 at the University of Pittsburgh Medical Center were retrospectively reviewed. Success was defined as resolution of ISS symptoms while preserving access function. J Vasc Surg. 2011 Jul;54(1):162-7. Epub 2011 Jan 26.
  • 25. 114 patients mean age of 65 years, female (66%), diabetic (61%), and brachial fistula (69%). Risk factors coronary artery disease (CAD; P < .001), hypertension (P < . 001), and tobacco use (P = .048). Women had more brachial origin access (odds ratio [OR], 3.1; P = .009). Forty-four patients with mild steal were observed. Seventy patients underwent 87 procedures. ligation (n = 27), banding (n = 22), DRIL (n = 21), improvement of proximal inflow (n = 9), revision using distal inflow (RUDI; n = 4), and proximalization of arterial inflow (PAI; n = 3). Early procedures (<30 days from the index fistula) were mostly ligation (50%) or banding (38%), while DRIL was the most frequent choice for late interventions (41%). Banding had a high failure rate (62%) and DRIL had a better success rate than banding (P ≤ .05).
  • 26. Conclusion Risk factors for development of ISS include CAD, diabetes, female gender, hypertension, and tobacco use. banding has a low success rate, while DRIL is particularly effective Less invasive treatment options such as RUDI and PAI may be quite effective in treating ISS.
  • 27. Algorithm to treat patients with symptoms of distal hypoperfusion ischemic syndrome Am J Kidney Dis 48: 88–97, 2006
  • 28. Thanks
  • 29. Digital Pressure Measurement (Plethysmography)
  • 30. Effect of compression of AV fistula on PPG curve
  • 31. Flow-based Access Creation 32
  • 32. Transonic (FMV) Vascular Flowprobes Available in a wide range of sizes (1.5 to 14 mm) Reusable Steam, ETO and Sterilizable 33
  • 33. Flow-based Vascular Access Management 34 Intraoperative Flowmeter Hemodialysis Monitor Endovascular Flowmeter
  • 34. intravascular coil insertion Angiograms show sequential coiling of arteries supplying the arteriovenous fistula. A, Angiography after coil embolization of distal radial artery beyond the arteriovenous anastomosis shows subsequent retrograde filling by the superficial palmar branch of the radial artery and carpal artery. B, Subsequent angiography after coil embolization of the superficial palmar branch (SPB) of the radial artery and carpal artery (C) seen in image A, as well an additional carpal artery (C) supplying the fistula. RA, Radial artery
  • 35. Diagnosis of ischemic steal -Digital pressure <60 mmHg (accuracy 92%, sens. 100%, spec. 87%) -Brachial/Digital Index <0.4 (accuracy 94%, sens. 92%, spec. 94%) -Digital pressure with compression is 20%> than without compression Schanzer A et al.: Vascular Medicine 2006; 11:1-5
  • 36. Ischemic Monomelic Neuropathy Rare, Global ischemic neuropathy Severe hand pain immediately post op Symptoms are out of proportion to degree of ischemic findings Treatment consists of immediate access ligation Prognosis is poor