Intervention for Access-Induced Ischemia: Which Option is the Best?

Abstract

Introduction

Access-induced ischemia is a rare but important surgical complication with potentially devastating long-term results. The question remains which therapeutic option is the best for the different forms of ischemia.

Method

A review of the literature concerning access-induced ischemia (classification, treatment) was performed; furthermore, our own experience of more than 300 cases with ischemia was discussed.

Results

There are four different stages of dialysis access-induced ischemia syndrome (DAIIS) that need adequate treatment: stage I conservatively, stage II fistula banding, stage III proximalization operation or distal revascularization interval ligation and stage IV closure of the access.

Discussion

According to the many publications and to our own experience, there are good therapeutic options for many of the patients with DAIIS. However, in case of extended lesions/gangrene, closure of the access should be discussed in time before major amputation becomes necessary.

Keywords

Access-induced ischemia Classification Therapy

Introduction

Access-induced ischemia is a rare but important surgical complication with potentially devastating long-term results. Pathophysiological changes of digital ischemia in patients with the need for hemodialysis are different from ischemia due to peripheral arteriosclerosis alone. Access-induced ischemia occurs in 1.6-8% of dialysis patients with different incidences depending on the type of arteriovenous fistula (AVF) (1, 2). “Steal phenomenon” is the result of altered hemodynamic flow; the term “steal syndrome” is used in case of clinical symptoms with the need for intervention (3). But the cause of ischemia is often multifactorial: The actual “steal” mechanism which is the result of retrograde flow out of the peripheral artery (4, 5), the blood diversion into the fistula (5), an underlying vascular disease such as peripheral arterial occlusive disease or mediasclerosis in diabetes mellitus (4, 6) and other pathologies. According to the different mechanisms, several forms and characteristics of access-induced ischemia, there is a wide consensus that the term “steal-syndrome” should not be referred to any longer; instead terms such as dialysis access-induced ischemia syndrome (DAIIS) or hemodialysis access-induced distal ischemia (HAIDI) should be used; however, no final consent concerning one term has been made yet. In the same way, different proposals of a classification of DAIIS have been published (2, 7, 8). All of them have in common that they try to describe the different clinical aspects as well as proposing therapeutic options. In this paper the classification of our own study group is used (8, Tab. I). Several surgical techniques have been described to treat DAIIS, such as fistula banding (9), distal revascularization interval ligation (DRIL) (10), proximalization of the arterial inflow (PAI) (11), revision using distal inflow (RUDI) (12), angioplasty of the artery (13), transposition of the radial artery (14) and others. The aim of this paper was to review publications dealing with dialysis access-induced ischemia in order to present the best therapeutic option in the different types of DAIIS according to the current literature and our own experience as a vascular center.

Table I

Classification of DAIIS

	Stage I	Stage II	Stage III	Stage IV
Symptoms	• mild symptoms: – livid discoloration – mild intermittent pain/numbness • no lesions	• severe pain during exercise and/or • permanent numbness • neurological deficiencies • no lesions	• dystrophy, atrophy • pain at rest • small lesions (acral necrosis <1 cm)	• extended lesions (finger/hand gangrene)
Clinical patterns	angiological verification acute onset	a: no neurological deficiencies b: additional neurological deficiencies acute onset	often combined with: – diabetes mellitus – PAOD latency >60 days	often combined with: - diabetes mellitus - PAOD • reduced general health state/life expectancy • latency >60 days
Therapy	preservation of HA conservative treatment	preservation of HA (banding procedure according to the fistula flow)	preservation of HA (interruption of retrograde flow, proximalization of the inflow)	no need for HD: closure need for HD: closure + permcath vs. creation of new HA

Stage I

Stage II

Stage III

Stage IV

Symptoms

•

mild symptoms:

–

livid discoloration

–

mild intermittent pain/numbness

•

no lesions

•

severe pain during exercise and/or

•

permanent numbness

•

neurological deficiencies

•

no lesions

•

dystrophy, atrophy

•

pain at rest

•

small lesions (acral necrosis <1 cm)

• extended lesions (finger/hand gangrene)

Clinical patterns

angiological verification acute onset

a: no neurological deficiencies

b: additional neurological deficiencies

acute onset

often combined with:

–

diabetes mellitus

–

PAOD

latency >60 days

often combined with:

- diabetes mellitus

- PAOD

•

reduced general health state/life expectancy

•

latency >60 days

Therapy

preservation of HA conservative treatment

preservation of HA (banding procedure according to the fistula flow)

preservation of HA (interruption of retrograde flow, proximalization of the inflow)

no need for HD: closure need for HD: closure + permcath vs. creation of new HA

HA = hemodialysis access; HD = hemodialysis; PAOD = peripheral arterial obstruction disease.

Materials and Methods

Databases including PubMED and Medline were searched using the terms “DASS,” “Steal syndrome,” “HAIDI,” “access-induced ischemia,” “DAIIS,” “DRIL,” “PAI” and “banding,” also using cross-references. A systematic review was not performed. Some 250 articles were found and peered. A publication was suitable for closer analyzation if:

a classification of access-induced ischemia was presented

surgical treatment options were presented or discussed

literature on access-induced ischemia was discussed

According to these premises 67 publications (35 cited) were focused on. Furthermore, our own experience of treating more than 300 patients for access-induced ischemia syndrome was imported. As this review is not systematic, no statistical calculations were performed. In this article we use the term “dialysis access-induced ischemia syndrome (DAIIS)” according to our own publication (15).

Pathophysiology of DAIIS

For a long time, steal phenomenon was seen as the major reason for the development of distal ischemia, leading to the term “steal syndrome.” However, it became obvious that the retrograde flow is physiological in most of the accesses (especially in radial fistulas) (16) but can also support ischemia syndrome in some cases (17). Other pathologies like high-flow mechanisms (18), stenotic inflow arteries, palmar arch syndrome (17) or diabetic arteriosclerosis of the distal arteries as well as the lack of vascular adaption of the forearm (19) have been described as reasons for distal ischemia since. Mostly, relevant access-induced ischemia occurs due to more than one factor (20), which makes therapeutic intervention more difficult. Clinically, symptoms and characteristics of ischemia syndrome differ according to the different underlying pathologies.

Classification of DAIIS

In order to categorize ischemia syndrome, several papers dealing with classifications of DAIIS have been published. The first one to describe different stages of DAIIS was Tordoir et al (2), who presented a classification similar to the one describing peripheral arterial disease. However, it became obvious that due to the different underlying pathologies as well as the fact that dialysis patients not necessarily resemble typical arteriosclerotic patients, this categorization did not reflect the clinical problems patients and doctors were confronted with. Our own group (8) as well as subsequently Scheltinga et al (7) presented different classifications that combined clinical and pathological features. Both classifications also include treatment options according to the different stages of DAIIS. In our clinic we have treated more than 300 patients with DAIIS, leading to several publications (8, 9, 15, 21). According to our results there are four stages of DAIIS, the first being intermittent numbness/coldness of the hand; the second being intermittent pain, ongoing numbness, neurological deficits (but no lesions); the third including permanent pain and small lesions and the fourth presenting with quick development of large lesions/gangrene, pain and/or neurological dysfunctions (Tab. I). As this classification turned out to be very helpful, it was used for this review.

Treatment options

Conservative treatment

If symptoms of DAIIS are mild and no lesions (as a sign of critical ischemia) exist, observation is justified. Measurements of distal perfusion such as ultrasound of the distal arteries (21) or finger pressures (19) are a good means of detecting “patients at risk.” Physical treatment (finger exercise, wearing a glove) can be helpful and lead to ongoing relief. However, constant clinical observation is mandatory in order not to miss symptoms of deterioration.

Angioplasty of the radial artery

In case of relevant stenosis of the radial artery (e.g., due to clamping), angioplasty might lead to an improved perfusion of both the fistula and the hand. All vessels of the arm, including the subclavian artery, have to be depicted by angiography in order not to miss proximal stenotic areas. The treatment of choice is balloon angioplasty. Even though this kind of DAIIS is rare, there have been reports on this method including interventional flow interruption (13, 17, 22).

Fistula banding

Fistula banding is one of the “old” principles to treat DAIIS by reducing the flow volume by narrowing the fistula vein diameter. However, fistula banding was often ineffective as the fistula flow was either insufficient or still too high postoperatively, leading to ongoing ischemia symptoms or to fistula thrombosis (23). In order to optimize this method, several publications describing the successful use of intraoperative flow measurements have been released (9, 18, 19, 24). Other options to prove a successful treatment are intraoperative duplex ultrasound, measurements of pulsations of the distal artery or Doppler signal. Scheltinga et al pointed out that intraoperative flow control generally leads to better results of banding procedure than without flow control (including indirect signs such as photoplethysmography) (23, Tab. II).

Table II

Results of banding procedure according to intraoperative flow control (23)

Author	Year	Patients (n)	Intraoperative control	Success (n)	Occlusion <3 months (n)
Thermann	2007	15	Fistula flow	10	1
Zanow	2006	79	Fistula flow	67	3
Goel	2006	16	Angiography	15	0
Ozisik	2003	6	Duplex ultrasound	6	0
Meyer	2002	7	Duplex ultrasound	7	0
Stary	2002	4	Pulsations	4	0
De Caprio	1997	11	PPG	10	9
Odland	1991	16	PPG	10	6

PPG = digital photoplethysmography: no direct measurement of improved flow.

DRIL (distal revascularization interval ligation)

DRIL was inaugurated with the aim to cease the retrograde flow by interrupting the cubital (in case of elbow fistulas) or radial (lower arm fistulas) artery distal of the arteriovenous anastomosis. In order to maintain distal perfusion, a venous bypass has to be performed. This method has been described to be successful in many cases of DAIIS (10, 25 –27), the reason for it being a combination of interruption of the retrograde flow and the PAI (see below).

PAI (proximalization of the arterial inflow)

Similar to DRIL, PAI was a new method of treating DAIIS (11, 15, 27). Main difference of this surgical approach was the insertion of a prosthetic graft as a semi-loop, moving the arterial inflow proximalwise, interrupting the former arteriovenous anastomosis and creating a new end-to-end anastomosis between the fistula vein and the graft, completing a loop flow. Different from DRIL, the original artery does not have to be ligated. In further studies it was proved that the proximalization of the inflow (taking the blood from a larger artery) as well as the interruption of the retrograde flow (giving up the old arteriovenous anastomosis) and an additional banding effect (by interpositioning a rigid graft prosthesis) lead to an improved distal perfusion (28). Even though the number of patients treated is limited, promising results were published during the last years (Tab. III).

Table III

Results of PAI (11, 15)

Author	Year	Patients (n)	Technical success (n)	Clinical success (n/%)	Patency rates^*	Mean follow-up (months)
Zanow	2006	30	30	25/84	87%/90%	26
Thermann	2010	40	40	36/90	62%/75%	24

Primary patency rate 1 year/secondary patency rate 3 years (Zanow) and 18 months (Thermann).

Thorax shunts

Thorax shunts (straight shunt artery to vein, “necklace shunt” (29) or loop shunt arterio-arterial (30)) have similar effects as DRIL or PAI, as the original artery is of a strong caliber. However, according to the literature, these shunts are mostly performed in patients with no remaining upper limb access options or in case of central venous stenosis. Even though in thoracic shunts DAIIS hardly occurs, it is not seen as the therapy of choice in case of DAIIS after peripheral accesses.

RUDI (revision using distal inflow)

The distalization of the arterial inflow from the cubital artery to either the radial or the ulnar artery is performed in order to achieve a better inflow into the hand. However, reports on this methods are rare (12). We have not performed this operation in our department yet.

AVF closure

If the limb is in acute danger (quickly developing necrosis of the fingers/hand) or in case of unsuccessful treatment by the above-mentioned techniques, fistula closure might become mandatory in order to prevent the patient from amputation. In such cases, however, a catheter has to be implanted or a new shunt created. Accordingly this treatment option is to be used only in emergency situations.

Discussion—consequences for treatment

Stage I DAIIS usually does not need invasive treatment. Retrograde flow mechanisms can be detected in almost 70% of patients with lower arm fistulas and usually do not lead to severe clinical symptoms. In many cases physical therapy as well as application of warmth (wearing a glove) is sufficient for reduction of symptoms. Still it must be kept in mind that in every patient worsening of symptoms is possible. Accordingly it is of high importance to find out which patient is at risk and therefore constant clinical surveillance is needed. In our clinic every patient who complains about pain or numbness/weakness postoperatively undergoes ultrasound examination and measurement of the finger pressure in order to measure the perfusion of the distal arteries (21). Furthermore physical treatment is offered. These patients are seen in our outpatient clinic within the following 2-4 weeks. If symptoms have improved, no further treatment is necessary. Otherwise further steps are discussed according to the clinical signs the patient presents (DAIIS stages >I).

Stage II DAIIS typically results from high-flow mechanisms. Patients show acute numbness, livid discoloration and severe pain, sometimes including neurological dysfunctions such as ischemic monomelic neuropathy (31 –33). Banding operation seems to be a very good therapeutic option as long as the proper way of diminishing the fistula flow is chosen by using intraoperative flow measurements (leaving a sufficient fistula flow for ongoing dialysis treatment). Several authors described very good results with this technique. However, there does not seem to be a relevant difference in the technique used (“tailoring,” simple banding, MILLER banding (9, 18, 24, 34)) concerning the clinical results. We prefer the tailoring technique (Fig. 1) as we find that the result resembles a tapered pipe avoiding turbulent flow. Generally, this operation is short and can be carried out under local anesthesia.

Fig. 1

Tailoring technique.

DAIIS stage III typically includes patients who suffer from diabetes mellitus and diabetic angiosclerosis; as typical clinical presentation DAIIS develops over weeks/months with acral lesions, pain and neurologic dysfunctions. The cause of this stage of DAIIS is a mixture of sclerosis of the distal arteries, high flow volumes and retrograde flow mechanisms (15, 19, 20). Banding as the sole treatment does not lead to sufficient results (8, 23). In such cases, conservative treatment as well as simple fistula banding is no adequate treatment. Our group presented very good results by using PAI, as this operation combines banding, interruption of the retrograde flow and improvement of perfusion by proximalization of the inflow (Fig. 2). The insertion of graft material did not lead to higher infections rates, but AVF thrombosis appeared more often. As mentioned earlier, DRIL is similar but does not have the banding effect (the fistula flow is not addressed), but, on the other hand, no graft material is used. Convincing results were also achieved with this technique (10, 19, 25 –27). We prefer PAI to DRIL as the operation is less invasive (no preparation of the vein, no interruption of a healthy artery) and can be performed in regional anesthesia. Other authors prefer DRIL because of the avoidance of graft material. However, as both aspects are reasonable, personal preference might lead to the decision making.

Fig. 2

Proximalization of the arterial inflow (PAI).

Stage IV DAIIS occurs in patients in a similar way as stage III DAIIS; however, there seems to be a relevant difference concerning the size and the time of the development of acral lesions. Stage IV patients have large necrosis/gangrene of a finger/hand that occurs within a relatively short period of time (weeks). According to our own experiences these patients are clinically in severely reduced health states and show high mortality rates. The treatment of such patients appears to be difficult. Our own group tried PAI or DRIL in some cases but experienced bad clinical results including higher complications (wound infections, graft infections) and little success concerning DAIIS (no adequate healing of the lesions, deterioration of the gangrene) (27). Therefore we are of the opinion that in such cases closure of the access has to be discussed before amputation of the hand becomes necessary (7, 8, 33, 35). Naturally, this means either creation of a new access at the other limb or the insertion of dialysis catheters. There is no specific data on the risk of DAIIS after creation of an access at the contralateral limb. However, as the anatomical situation usually is similar at both arms, DAIIS might also develop at the other arm. We experienced both, the uneventful creation of a new access as well as severe DAIIS at the other arm. In the end the decision whether or not to create a new access vs. implantation of a catheter has to be made individually. However, if a new access is created, one should survey the patient very closely to be able to react quickly in case of DAIIS. If a catheter is to be implanted, we prefer jugular tubes in order not to compromise the subclavian vein. This can be performed easily by puncturing the jugular vein, inserting the catheter and tunnulating it subcutaneously so that it can be diverted infraclavicularly. Second vessel of choice is the subclavian vein. We generally do not use the femoral vein.

Conclusion

There are four stages of DAIIS that need different therapeutic treatments. According to our own experience as well as to a review of the literature, conservative treatment can be useful in stage I, fistula banding in stage II and PAI or DRIL in DAIIS stage III. Stage IV (large lesions, gangrene, bad health state) often requires closure of the access in order to prevent amputation or enable minor amputation.

Footnotes

Financial support: None.

Conflict of interest: None declared.

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