Management of steal syndrome. Dr Ravi Bansal

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%

4. 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

5. 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

6. 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

7. 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

8. 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.

9. Treatment Goal
Reversing the Ischemia
Preserving the Access

10. 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

11. 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

12. 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

13. Percutaneous Balloon
Angioplasty
Detection of proximal arterial stenosis
Study of the arterial anatomy distal to AV
access, for planning corrective procedure

14. Intravascular stent insertion

15. Treatment of steal
syndrome in a
distal radiocephalic
arteriovenous
fistula using
intravascular coil
embolization
JOURNAL OF VASCULAR SURGERY 2008 , 47(2), 457-9

16. 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

17. 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)

18. Banding
Banding a low flow
access to a degree where
steal syndrome
disappears will result in
inefficient dialysis or
even access thrombosis

19. • excision of a portion
of the vein and
plication with
mattress or
continuous sutures
• crossed PTFE band
• interposition of a 4
mm PTFE

20. 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

21. 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%

22. 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

23. DRIL in AV
Graft

24. 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%

25. 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.

26. 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).

27. 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.

28. Algorithm to treat patients with symptoms of
distal hypoperfusion ischemic syndrome
Am J Kidney Dis 48: 88–97, 2006

29. Thanks

30. Digital Pressure Measurement
(Plethysmography)

31. Effect of compression of AV
fistula on PPG curve

32. Flow-based Access Creation
32

33. Transonic (FMV) Vascular
Flowprobes
Available in a wide range of sizes
(1.5 to 14 mm)
Reusable
Steam, ETO and Sterilizable
33

34. Flow-based Vascular Access
Management
34
Intraoperative Flowmeter
Hemodialysis Monitor
Endovascular Flowmeter

36. 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

37. 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

39. 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