Steal syndrome solutions proposed amid assessment of ischaemia risks

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VIETHsymposium (15–19 November, New York City, USA) has played host to a “mini-symposium” on the risk of steal syndrome and distal ischaemia posed by vascular access for haemodialysis. Moderated by John E Aruny (Dialysis Access Institute, Orangeburg, USA) and Clifford M Sales (Mount Sinai School of Medicine, Summit, USA), it saw prominent vascular access voices tackle the issue and propose means of mitigating it. 

First to speak was William Jennings (University of Oklahoma School of Community Medicine, Tulsa, USA), who gave a presentation reviewing his published findings that even patients “at high risk of hand ischaemia” could have “a safe and functional arteriovenous fistula (AVF) established” for vascular access. Haemodialysis access-induced distal ischaemia (HAIDI) is a particular risk, he said, for individuals with peripheral vascular disease, diabetes, a history of any amputation, previous steal syndrome, females, and older patients, among others. 

Jennings set about outlining methods for minimising the risk of HAIDI, including “more (and more successful) distal radiocephalic AVFs” as well as proximal radial artery inflow. He noted too that “reports of percutaneous AVFs all note a very low incidence of HAIDI,” referencing the 2020 Ellipsys study by Alexandros Mallios (Hôpital Paris Saint-Joseph, Paris, France) et al and the 2017 WavelinQ NEAT trial published by Charmaine Lok (University of Toronto, Toronto, Canada) et al in the American Journal of Kidney Diseases (AJSN). 

Following Jennings came Matthew J Dougherty (Pennsylvania Hospital, Philadelphia, USA), who explored strategies for managing steal syndrome and neuropathy related to dialysis access. Dougherty provided statistics on the prevalence of steal, which affects 10–20% of dialysis patients. Of those, 4–6%  require intervention, he said, while also noting that while neuropathy of various etiologies was experienced by between 10 and 40% of dialyisis patients, ischemic monomelic neuropathy (OMN) affects fewer than 1%.  

He differentiated the two conditions, noting that steal has a slower, less conspicuous onset than IMN which is “immediate.” Steal, he said, is associated more with vascular access at the distal brachial level, while IMN is almost exclusively associated with diabetes. Dougherty proposed an algorithm for the work-up and management of neuropathy and steal syndrome, with a diminished emphasis on the distal revascularisation and interval ligation (DRIL) procedure as the dominant option, which was shared by the panel. 

Outlining treatment options, Dougherty pointed to ligation, which he described as “simple” and a way of restoring a patient’s baseline anatomy. Banding, meanwhile, he described as “a poor choice for low flow” and “less predictable” than alternative treatments, but said it was better for veins than prosthetics. For low-flow patients, he did suggest DRIL. 

He also examined revision using distal inflow (RUDI) but said it shared problems with banding and that clinical data on the procedure were limited. He advocated perhaps most strongly for minimally invasive limited ligation endoluminal-assisted revision (MILLER) as a steal treatment, referring to Gregg Miller (American Access Care of Brooklyn, Brooklyn, USA) et al’s 2009 retrospective analysis study in Kidney International which described the “minimally invasive” procedure as “effective and durable.” 

Yana Etkin (Zucker School of Medicine at Hofstra / Northwell, Hempstead, USA) followed this with her own presentation examining a modified banding technique as a treatment option for distal ischaemia. She distinguished first between high flow rate steals, adequate and low flow rate steals and severe ischaemia, all of which demand different treatments. Modified banding is only appropriate as a treatment for high flow rate steals, she said, echoing Dougherty.  

She stated that overall banding is associated with a “high rate of failure” and complications. Drawing on a Journal of Vascular Surgery (JVS) study by Andrew E Leake (Vascular Surgery Associates of Richmond, Henrico, USA) et al from 2015, Etkin made the claim that banding could benefit from “intraoperative measurement of distal perfusion” as a “simple and effective adjunct” that could be easily performed, requiring no “special equipment or personnel.” 

“HAIDI could lead to devastating complications including loss of digits or even limbs in a small group of patients,” Etkin said later to Renal Interventions. “We are continuing to improve our techniques to manage this challenging problem.” 

The symposium explored a variety of treatments for steal and neuropathy, before a concluding presentation which diverged into vascular access haemorrhage.

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