ISCHEMIC STEAL Prepared by Nader Saad

SYNDROME (ISS)
 WHAT IS ISS?
Definition:

ARHI is locoregional hypoperfusion secondary to inadequate arterial

compensation.
oAV access is associated with reduction of distal blood flow in up to 80% of cases

oCoolness and tingling can be present in up to 10% with many resolving in a few weeks

oOnly a handful of patients develop symptomatic ischemia.

oIschemia of the hand occurs when flow through the arterial segment distal to the arteriovenous fistula is significantly reduced or reversed.
 EPIDEMIOLOGY
Significant ischemia related to steal syndrome:

o More common with brachial-based access with an incidence of 4% to 8%.

o Less common with radial-based access with an incidence of 1% to 2%.

o Symptoms were classified as:

”Acute" (<24 hours after AV access construction), ”Subacute" (within one

month), or "chronic" (after one month)
 PATHOPHYSIOLOGY

Creation of an access substantially alters flow dynamics and resistance in

the extremity.
The arterial inflow supplies two competing circuits— Low-resistance
access proximally and the high-resistance peripheral vascular bed distally.
Reversal of flow in a portion of the arterial tree distal to the anastomosis is
common after access creation and is termed “physiologic steal”
73% of autogenous accesses
91% of prosthetic accesses.
Reversal is neither necessary nor sufficient to cause distal ischemia.
 RISK FACTORS
General risk factors :
1. Female sex
2. DM
3. Peripheral arterial disease (PAD)
4. Prior episodes of access-related hand ischemia (ARHI)
5. Multiple previous access procedures.
 RISK FACTORS (2)
Access related characteristics:
1. Brachial artery–based accesses
2. Prosthetic grafts
3. Translocated femoral veins.

Prosthetic conduits are more likely associated with the development of acute steal syndrome,
whereas autogenous access would be expected to contribute to the development of
chronic steal syndrome as vein capacitance evolves over time.
STRATEGIES FOR
PREVENTION
1. Identifying correctable arterial lesions 
Noninvasive testing :

Full upper extremity pulse examination,

Full duplex ultrasound mapping of bilateral upper extremity arteries and veins.

2. Avoiding brachial artery inflow

Most important strategy available

Using the proximal radial artery rather than the brachial artery for inflow when more distal arterial inflow is not feasible

3. Limiting proximal arterial inflow

Limiting the length of the arteriotomy to a maximum of 4 to 6 mm 

Utilizing end-to-side anastomosis configuration

4. Limiting venous outflow

PROXIMAL RADIAL ARTERY FOR
INFLOW
 DIAGNOSIS
Immediately in the recovery room after placement of an upper arm arteriovenous
graft, the patient reports severe hand pain.

What are the next steps in management?

 DIAGNOSIS
Patients may present with a wide spectrum of signs/symptoms depending upon the
severity of ischemia :

Numbness, burning pain, and severe weakness within hours of access creation.

Acute ARHI (<24 hours) is rare but more likely with prosthetics.
 DIAGNOSIS
Patients with acute ARHI/Steal syndrome typically present with
acute ischemic symptoms :
1. Pain
2. Pallor
3. Paralysis
4. Pulselessness
5. Paresthesia
6. Poikilothermia
 DIFFERENTIAL DIAGNOSIS
1. ARHI
2. Peripheral arterial disease
3. Carpal tunnel syndrome
4. Venous hypertension
5. Ischemic monomelic neuropathy (IMN).
 DIAGNOSIS
Physical findings:
Cool extremity Pallor Cyanosis

Delayed capillary refill Absent pulses/signals Weak grip

Diminished sensation Ulceration Gangrene

Improvement with access compression confirms the diagnosis and predicts a good response to
revision
 DIAGNOSIS
Diagnostic Testing:
1. Digital pressure measurement
2. Photoplethysmography (PPG)
3. Pulse oximetry
4. Color duplex ultrasound
5. Angiography
 DIAGNOSIS
Modaghegh et al.
Attempted to define clinically relevant thresholds for DBI and pulse oximetry and
found that a DBI of less than 0.7 was 100% sensitive but only 73% specific.

With respect to pulse oximetry, they identified a threshold of 94% (sensitivity 80%,
specificity 92.5%).
 DIAGNOSIS
Angiography should be the first step in intervention

Angiography can identify a causative inflow stenosis ( Culprit in

15% to 20% of cases ) and should include imaging of aortic arch
to hand
 DIAGNOSIS
Duplex ultrasound with access flow measurements should also be obtained to
determine flow rates to facilitate the planning of intervention.

AV access flow can be defined as :

•Low (<600 mL/min)
•Normal (600 to 1500 mL/min)
•High (>1500 mL/min) 
The Society for Vascular Society (SVS) steal syndrome classification:
Grade 0: No symptoms

Grade 1: Mild Cool extremity, few symptoms, flow

augmentation with access occlusion
Grade 2: Moderate Intermittent ischemia only during
dialysis, Claudication
Grade 3: Severe Ischemic pain at rest, tissue loss and
ulceration
 DIAGNOSIS
Immediately in the recovery room after placement of an upper arm arteriovenous
graft, the patient reports severe hand pain.
Ischemic monomelic neuropathy (IMN) is particularly important to
consider as it presents very similarly to steal syndrome and can result in permanent
damage if not addressed in a timely fashion.
 IMN VS ISS
IMN:
1. Immediate symptoms following access placement
2. Frequently have palpable wrist pulses
3. Absence of ischemic symptoms
4. Treatment of IMN is access ligation
Steal syndrome:
5. Symptoms develop over weeks to months and occasionally years after access creation
6. Ischemic symptoms
7. Resolution of symptoms with access compression.
8. Treatment of acute steal syndrome is immediate revision.
Copyrights apply
 TREATMENT : DECIDING WHICH PATIENTS
REQUIRES INTERVENTION

Transient, mild symptoms :

Spontaneous resolution within a few weeks

Expectant measures : Stabilize blood pressure and prevent hypotension ( During HD), and a warming glove can be used.

Ischemic pain with arm activity/during hemodialysis:

Closer monitoring for severe symptoms

Progressive numbness or pain, pallor of the hand, diminished sensation, ischemic ulcers, progressive dry gangrene,
decreased motor function, or atrophy of the hand muscle

Although noninvasive studies can be helpful in monitoring the progression of steal syndrome, The timing of the intervention
should ultimately be guided by symptoms.
 TREATMENT : GOALS
Surgical intervention ideally focuses on :

1. Symptoms resolution

2. Salvaging the existing access. ( Access preservation )

Treatment of hemodialysis access-induced distal ischemia 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
 TREATMENT :
CONSIDERATIONS
1. Patients with a history of ISS are at increased risk of developing future ISS :
Avoid usage of large conduit or graft when creating a future access.
2. Any patient presenting with manifestation of steal syndrome should undergo an
evaluation for PAD.
3. Inflow stenosis at the level of the subclavian artery commonly contributes
to steal syndrome symptoms and can be corrected with endovascular
intervention.
TREATMENT: OPERATIVE
MANAGEMENT
These include two basic strategies: (Flow-dependent treatment can be summarized )

1. A high-flow AV access (>1500 mL/min) may require only flow reduction.

2. A low- or normal-flow AV access (≤1500 mL/min) will require a revascularization

Options include:
-Banding/Flow limiting procedures
-Revision using distal inflow (RUDI)
-Proximalization of arterial inflow (PAI)
- Distal revascularization with interval ligation (DRIL)
- Angioplasty
- Distal radial artery ligation (DRAL)
- Ligation
 TREATMENT : LIGATION VS
SALVAGE
Prosthetic accesses :

Lower patency rates than autogenous accesses.

Graft salvage may not be worthwhile :

-Expected patency is limited -Acute presentation

Fistula functionality:

Longstanding fistula that is functioning well, aggressive attempts should be made at salvage.

Ligation is a last resort in those with limited life expectancy, severe tissue loss, or a poorly functioning access.
TREATMENT-FLOW-LIMITING
PROCEDURES : BANDING (1)
Banding :
Creation of a stenosis near AV access site
Higher proportion of the arterial inflow is directed toward the hand

Minimally invasive limited ligation endoluminal-assisted

revision (MILLER) :
1. A 4- to 5-mm endoluminal balloon placed percutaneously as a sizing dowel.
2. A small incision is made near the anastomosis, allowing a suture to be secured around the access
with the balloon inflated.
Miller and colleagues achieved significant clinical improvement in 89% of 114 patients with an
early thrombosis rate of only 4.4%
TREATMENT: BANDING (2)
Limitations:
Difficulty in predicting determine the degree of stenosis that will eliminate ischemia
without endangering access patency
Access flow of 700 mL/ min is an important cutoff for maintenance of access
patency
Need of physiologic testing and flow monitoring (Anesthesia-induced changes can
make these tests inaccurate)
Higher rates of access thrombosis than alternatives
TREATMENT: BANDING (3)
Banding procedures in any form are most reasonable for a patient with a marginal
access and severe comorbidities in that it limits the stress of the procedure while still
providing an attempt at access salvage.
TREATMENT: FLOW-LIMITING
PROCEDURES
Revision Using Distal Inflow (RUDI):

This technique relocates the arterial inflow more distally by ligating the existing
access at its origin and placing an interposition graft from the arterial inflow just
beyond the brachial artery bifurcation to the venous outflow of the existing access.

Traditionally, the conduit of choice is greater saphenous vein.

 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
TREATMENT: DIRECT AUGMENTATION OF
PERIPHERAL FLOW

Proximalization of Arterial Inflow (PAI):

The existing arteriovenous anastomosis is ligated and using a small-caliber (4 to

5 mm) prosthetic interposition is placed between a more proximal portion of the
brachial artery and the proximal venous portion of the existing access.

PAI effectively lengthens the access, thus decreasing flow through the access.

The primary advantage is preservation of the native artery’s continuity

TREATMENT: DIRECT
AUGMENTATION OF
PERIPHERAL FLOW
Distal Revascularization–Interval Ligation (DRIL):
A bypass is created from the proximal brachial artery to the proximal radial artery in
the forearm, and the intervening segment of the artery between the arteriovenous
anastomosis of the access and the distal bypass anastomosis is ligated to prevent
retrograde flow.
This prevents retrograde flow from the distal vessels and creates a low-resistance
pathway for blood to reach the peripheral vascular bed.
TREATMENT: DIRECT
AUGMENTATION OF
PERIPHERAL FLOW
Distal Revascularization–Interval Ligation (DRIL):
Drawbacks:

1. Invasive procedure
2. Dependance of the hand on the bypass.
3. DRIL requires available autogenous conduit.
An area of reduced pressure called a pressure sink
exists in the artery just proximal to the anastomosis.
This exists because the large capacitance of the venous
outflow causes pressure to
fall rapidly, reaching central venous pressure within 1
cm of the anastomosis.

Locating the origin of the bypass 7 to 10 cm

above the inflow anastomosis avoids this pressure
sink.
DISTAL ARTERY OCCLUSION (DRAL)

oISS is rare with radio-cephalic AV fistulas,

oOcclusion of the distal artery, which eliminates flow reversal, is an option
unique to this site provided the ulnar artery is patent.
oDistal radial artery occlusion can be accomplished by embolization or with
open surgical ligation
Duplex ultrasound preoperatively:
1. Confirmation of flow reversal
2. Confirmation of ulnar artery patency
3. Improvement in digital waveforms should be demonstrated by
compressing the AV access or the radial artery distal to the AV fistula.
LONG-TERM
FOLLOW-UP/SURVEILLANCE
Understand how to address ongoing steal symptoms after intervention.
 Chronic ischemic insult may contribute to ongoing neuropathic symptoms even after ligation or
otherwise adequate reperfusion. This damage may be irreversible.
 Noninvasive studies can be repeated postoperatively to confirm restoration of adequate distal
perfusion.
 In these cases, patients typically experience overall clinical improvement with only mild residual
symptoms.
LONG-TERM
FOLLOW-UP/SURVEILLANCE
Recognize appropriate surveillance following RUDI or DRIL

 Patients undergoing RUDI or DRIL with a saphenous vein conduit are at risk for wound
complications related to the vein harvest site. Many established risk factors for wound complications
at this site overlap with risk factors for ARHI, including female sex and DM.

 DRIL bypass patency can be monitored with duplex imaging, usually at 3 months, 6 months, and 1
year.
LONG-TERM
FOLLOW-UP/SURVEILLANCE
Describe future access options in a patient whose attempt at access salvage fails.
 Patients who experience ARHI are at risk for the development of ARHI in the future. This should be
considered when deciding on new access. For example, attempts should be made to create a new
access that is distal in the arm rather than brachial based.

 Transitioning to peritoneal dialysis may be preferred for patients who are candidates.