Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal...

31
Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate Professor, TAMU HSC Temple, Texas March 7 th , 2019

Transcript of Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal...

Page 1: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Interventions for Dialysis Access

Steal Syndromes

W. Todd Bohannon, MD

Director, Division of Vascular Surgery

Clinical Associate Professor, TAMU HSC

Temple, Texas

March 7th, 2019

Page 2: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Disclosures

• None.

1

Page 3: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

2

• First described by

Storey et al in 1969

• Extremity ischemia

induced by the

shunting of significant

arterial flow through

an AV access thereby

reducing distal

perfusion.

Introduction

Page 4: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

3

• Digital blood flow reduced in 80% of access cases.

– Only few with symptoms.

– 10% with coolness and tingling that often resolves.

• Clinically significant steal.– Autologous 1-2%

– Brachial 4-8%

Introduction

Page 5: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Hemodynamics

Understanding Strategies for the Treatment of Ischemic StealSyndrome after Hemodialysis AccessWixon, et al. J Am Coll Surg 2000;191:301–310

Blood flow in large fistulas is independent of the fistula diameter

and depends more on the resistance of the inflow artery, the

peripheral circulation, and the collateral network.

Page 6: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Pathophysiology

• Low resistance venous outflow and high resistance arterial bed.

• Distal disease with stenosis or inability to vasodilate.

• Augmentation of symptoms by hypotension and decreased cardiac output accompanying dialysis.

Page 7: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

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 rest pain, tissue loss

Page 8: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Risk Factors

• Diabetes

• PAD

• CAD

• Brachial based access

• Pre-op DBI < 0.6

• Digit pressure <60mmHg

Tynan-Cuisinier. Eur J Vasc Endovasc Surg 2002 (32) 309-315.

Page 9: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Steal Symptoms

• Symptoms present either <24hrs or weeks

to months post-op.

• Burning

• Numbness

• Paresthesias

• Weakness

• Coolness

Page 10: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Steal Signs

• Cyanosis

• Delayed cap refill

• Pallor

• Absent pulses/signals

• Diminished sensation

• Weakness

• Ulcers/Gangrene

• Improvement with access occlusion

Page 11: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Differential Diagnosis

• Ischemic Monomelic Neuropathy (IMN)

must be considered for acute post-op

presentation.

• Carpal Tunnel Syndrome.

• Venous hypertension.

Page 12: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Evaluation for Steal: PPG

Page 13: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

12

• High flow

(>900ml/min)

• Retrograde flow

Evaluation for Steal: Duplex

Strandness's Duplex Scanning in Vascular Disorders, 5th Edition. Wolters Kluwer Health, 20151027.

Page 14: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Evaluation for Steal: Angiography

Page 15: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

14

Aim

• Reduce access flow

• Augment peripheral flow

Goal

• Resolve symptoms.

• Preserve access.

Treatment

Page 16: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

15

• Banding.

– Miller Procedure.

• DRIL.

• RUDI.

• PAI: Proximal arterial

inflow.

• Ligation.

Treatment Options

15Tynan-Cuisinier. Eur J Vasc Endovasc Surg 2002 (32) 309-315.

Page 17: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Banding

• Variable success

rates reported

• Flow monitoring

• Miller/Modified-

Miller techniques.

Page 18: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Minimally Invasive Limited Ligation

Endoluminal-assisted Revision (MILLER)

• Used for fistula revision

in the setting of steal

syndrome.

• Controlled ligation (non-

absorbable suture) of

the fistula with the aid

of a balloon.

Page 19: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Minimally invasive limited ligation

endoluminal-assisted revision

(MILLER)

• 57 year old woman with right hand pain and

numbness, worse during dialysis.

• Right radiocephalic fistula created 5 months

prior.

Page 20: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

MILLER procedure

Fistula open Fistula occluded

Page 21: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

MILLER procedure (photo’s from recent pt)

Page 22: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

MILLER procedure

Page 23: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Distal Revascularization-Interval Ligation

(DRIL)

• Creates a bypass proximal to the arterial anastomosis and to the vessel distal.

• Ligation to the vessel distal to arterial anastomosis.

• Prevents retrograde flow from the distal vessel.

• Lower resistance pathway distally.

Page 24: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

23

Revision Using Distal Inflow (RUDI)

• Ligation of fistula at the

arterial anastomosis.

• Inflow moved to a more

distal vessel.

• Decreases flow through

the access due to

diameter reduction in

the fistula and smaller

inflow artery.

Page 25: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

24

Proximalization of Arterial Inflow (PAI)

Zanow, et al. J Vasc Surg 2006;43:1216-21

Maintains arterial continuity.

Page 26: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Operative configurations

- DRIL and RUDI usually autologous conduit.

- PAI usually prosthetic conduit.

Page 27: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Treatment Algorithm for Steal

Page 28: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Ligation

• Definitively resolves steal symptoms.

• Sacrifices functional access.

• Last resort for steal.

• First line for Ischemic MonomelicNeuropathy (IMN) .

Page 29: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Summary

• Clinically significant access related hand

ischemia can be a serious threat to a

functioning dialysis access.

• There are numerous successful strategies

to manage and preserve access in patients

with steal syndrome.

28

Page 30: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

Selected References

• Robert C. Knox, Scott S. Berman, John D. Hughes, Andrew T. Gentile, Joseph L. Mills, Distal revascularization-interval ligation: A durable and effective treatment for ischemic steal syndrome after hemodialysis access, Journal of Vascular Surgery,Volume 36, Issue 2, 2002, Pages 250-256.

• A Miller, Gregg & Goel, Naveen & Friedman, Alexander & Khariton, Aleksandr & C Jotwani, Manish & Savransky, Yevgeny & Khariton, Konstantin & P Arnold, William & Preddie, Dean. (2009). The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome. Kidney international. 77. 359-66.

• Minion. David J. et al. Revision Using Distal Inflow: A Novel Approach to Dialysis-associated Steal Syndrome Annals of Vascular Surgery , Volume 19 , Issue 5 , 625 – 628.

• Rutherford’s Vascular Surgery and Endovascular Therapy, 9th Edition Elsevier

• Strandness's Duplex Scanning in Vascular Disorders, 5th Edition. Wolters Kluwer Health, 20151027.

• Christopher L Wixon, John D Hughes, Joseph L Mills, Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access11No competing interests declared.,Journal of the American College of Surgeons, Volume 191, Issue 3,2000, Pages 301-310.

• Jurgen Zanow, Ulf Kruger, Hans Scholz. Proximalization of the arterial inflow: A new technique to treat access-related ischemia. Journal of Vascular Surgery, Volume 43, Issue 6, 2006,Pages 1216-1221.

Page 31: Interventions for Dialysis Access Steal Syndromes · Interventions for Dialysis Access Steal Syndromes W. Todd Bohannon, MD Director, Division of Vascular Surgery Clinical Associate

RUDI vs. DRIL

30