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Indications for surgical treatment of angioaccess-induced arterial "steal".

Abstract：

BACKGROUND:Arterial "steal" is a well-known complication following proximal arteriovenous (AV) fistula, but its manifestations comprise a wide spectrum of symptoms and there are no clear indications for those patients who need surgical repair. STUDY DESIGN:Among 180 consecutive AV fistulas of various configurations, with the brachial artery as the donor artery in all patients, 111 patients were studied retrospectively (group A) and 69 patients were studied prospectively (group B). Patient records were reviewed in group A, and the decision for surgical correction of limb-threatening steal was based on clinical grounds only. In group B, all patients were followed prospectively; postoperative systolic blood pressure measurements were obtained, and a systolic pressure index (SPI) was calculated (postoperative forearm systolic pressure divided by contralateral forearm systolic pressure). In patients with an SPI < 0.6, nerve conduction studies (NCS) were performed. The decision for operation in this group was based on clinical examination, SPI, and NCS. RESULTS:Seven patients were operated on for steal-induced limb-threatening ischemia; in all seven patients, ischemia developed immediately after access construction. One additional patient with mild symptoms and deterioration in repeated NCS was considered a candidate for ischemic monomelic neuropathy and was successfully operated on 1 month later. The ligation-bypass technique was used in all patients, consisting of arterial ligature distal to the takeoff of the graft and short arterial bypass from a point proximal to the inflow of the access to a point just distal to ligation. In 94% of the patients, some degree of distal ischemia was detected (SPI < 0.8); patients with SPI < 0.5 were most likely to have impaired NCS. CONCLUSIONS:Steal-induced limb-threatening ischemia necessitating immediate surgical repair occurred in 3.9% (7 of 180) of our patients. The decision for surgical correction of steal should be based on clinical examination. Nerve conduction studies may be useful in patients who have an SPI value < 0.5 to detect candidates who might develop ischemic monomelic neuropathy. In similar patients, surgical treatment of steal should be offered.

journal_name

J Am Coll Surg

journal_title

Journal of the American College of Surgeons

authors

Lazarides MK,Staramos DN,Panagopoulos GN,Tzilalis VD,Eleftheriou GJ,Dayantas JN

doi

10.1016/s1072-7515(98)00139-2

subject

Has Abstract

pub_date

1998-10-01 00:00:00

pages

422-6

issue

eissn

1072-7515

issn

1879-1190

pii

S1072751598001392

journal_volume

187

pub_type

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Indications for surgical treatment of angioaccess-induced arterial "steal".