Does this patient have dialysis-associated vascular steal syndrome?
Symptoms (the classic 6 Ps)
Symptoms worsen during dialysis particularly in the setting of intradialytic hypotension, and during cold weather
Dialysis-associated muscle cramp
Diabetic or uremic polyneuropathy
Entrapment neuropathy including beta-2 microglobulin amyloidosis
Reflex sympathetic dystrophy
Acute ischemic monomelic mononeuropathy (ischemic nerve injury following the creation of an arteriovenous fistula or graft)
What tests to perform?
This is a clinical diagnosis based on the history and physical examination; noninvasive and invasive imaging studies may be used to support the diagnosis.
Pulse oximetry (decreased waveform, pulse gradient compared with unaffected side, oxygen desaturation on affected side if severe)
Digital-brachial index (DBI), which is the ratio of the brachial to digital blood pressure (measured on the fingers)
No absolute value for the index to predict the development of steal; DBI < 1.0 suggests increased risk
DBI < 0.6 provides a sensitivity of 100% and a specificity of 76%
DBI < 0.8 provides a sensitivity of 29% and a specificity of 93%
Doppler flow (diminished pressure and waveform on the affected side with the corresponding wrist/brachial index)
How should patients with dialysis-associated vascular steal syndrome be managed?
Depends on severity and vascular access anatomy
Mild (cool extremity with few symptoms but steal demonstrable by flow augmentation with access occlusion): Supportive and symptomatic care: use of gloves and hand exercise
Moderate (intermittent ischemia only during dialysis/claudication): vascular intervention required if supportive care fails or symptoms worsen
Percutaneous luminal angioplasty (inflow or outflow arterial disease)
Surgical intervention with preservation of vascular access:
Correction of arterial inflow stenosis/occlusion
Flow limiting procedures (e.g., banding, outflow reduction, or anastomosis reduction)
Proximalization of arterial anastomosis
Revision using distal inflow
Ligation of artery distal to anastomosis
Distal revascularization and interval ligation (DRIL)
Distal revascularization without interval ligation
Severe (ischemic pain at rest/tissue loss)
Surgical ligation of vascular access with loss of access
What happens to patients with dialysis-associated vascular steal syndrome?
Vascular access dysfunction
How to utilize team care?
Specialty consultations: vascular medicine and vascular surgery
Nurse: Promote hand exercise
Pharmacist: Review and check drugs that may worsen vasoconstriction such as beta-blockers
Are there clinical practice guidelines to inform decision making?
2006 Clinical Practice Guidelines for Vascular Access (Published by National Kidney Foundation, K/DOQI)
ICD-10-CM diagnosis code T82.818A: Embolism of vascular prosthetic devices, implants and grafts, initial encounter
ICD-10-CM diagnosis code T82.828A: Fibrosis of vascular prosthetic devices, implants and grafts, initial encounter
ICD-10-CM diagnosis code T82.838A: Hemorrhage of vascular prosthetic devices, implants and grafts, initial encounter
ICD-10-CM diagnosis code T82.848A: Pain from vascular prosthetic devices, implants and grafts, initial encounter
ICD-10-CM diagnosis code T82.858A: Stenosis of vascular prosthetic devices, implants and grafts, initial encounter
ICD-10-CM diagnosis code T82.868A: Thrombosis of vascular prosthetic devices, implants and grafts, initial encounter
ICD-10-CM diagnosis code T82.898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter
What is the evidence?
“Clinical practice guidelines for vascular access”. Am J Kidney Dis.. vol. 48. 2006. pp. S176-247.
Scali, ST, Huber, TS. “Treatment strategies for access-related hand ischemia”. Semin Vasc Surg.. vol. 24. 2011. pp. 128-36.
Suding, PN, Wilson, SE. “Strategies for management of ischemic steal syndrome”. Semin Vasc Surg.. vol. 20. 2007. pp. 184-8.
Leake, AE, Winger, DG, Leers, SA, Gupta, N, Dillavou, ED. “Management and outcomes of dialysis access-associated steal syndrome”. J Vasc Surg. vol. 61. 2015 Mar. pp. 754-60.
Mickley, V. “Steal syndrome–strategies to preserve vascular access and extremity”. Nephrol Dial Transplant. vol. 23. 2008 Jan. pp. 19-24.
Polkinghorne, KR, Chin, GK, MacGinley, RJ, Owen, AR, Russell, C, Talaulikar, GS, Vale, E, Lopez-Vargas, PA. “KHA-CARI Guideline: vascular access – central venous catheters, arteriovenous fistulae and arteriovenous grafts”. Nephrology (Carlton). vol. 18. 2013 Nov. pp. 701-5.
Tordoir, J, Canaud, B, Haage, P, Konner, K, Basci, A, Fouque, D, Kooman, J, Martin-Malo, A, Pedrini, L, Pizzarelli, F, Tattersall, J, Vennegoor, M, Wanner, C, ter Wee, P, Vanholder, R. “EBPG on Vascular Access”. Nephrol Dial Transplant. vol. 22. 2007. pp. ii88-117.
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- Does this patient have dialysis-associated vascular steal syndrome?
- What tests to perform?
- How should patients with dialysis-associated vascular steal syndrome be managed?
- What happens to patients with dialysis-associated vascular steal syndrome?
- How to utilize team care?
- Are there clinical practice guidelines to inform decision making?
- Other considerations