Distal limb ischemia secondary to a dialysis arteriovenous (AV) access can present with a wide range of symptoms. Because most dialysis AV accesses are created in the upper extremity, the common terminologies used to refer this phenomenon are distal hand ischemia, distal hypoperfusion ischemic syndrome, steal syndrome, and hand ischemia associated with dialysis vascular access.1 The common presenting symptoms are coldness, numbness, and pain in the distal extremity that worsens during a hemodialysis treatment, as well as weakness and tissue loss/gangrene for severe cases. The challenge for the dialysis providers is to differentiate early ischemic symptom of hand pain from other pathologies such as carpal tunnel syndrome, distal arthropathy, and neuropathic pain. The high incidence of multiple comorbidities, such as diabetes mellitus, atherosclerosis, and peripheral artery disease, in the dialysis population poses a real challenge to reach an accurate diagnosis and plan for an ideal therapeutic intervention.2
Most patients who present with mild steal symptoms are easily managed conservatively. Those presenting with moderate and severe ischemic symptoms pose a tough treatment conundrum. While salvaging an AV access with an intervention to treat symptoms is preferred, often the options available are limited to ligation and losing an AV access requiring a plan to create a new AV access with the risk of recurrence. The undesirable interim option of transitioning to a central vein catheter is suboptimal because of its associated higher risk of infection and the impact on quality of life.
The reported incidence of distal ischemia from AV access ranged from 1.6% to 8% mainly from retrospective studies and is likely underreported or under-recognized because those with milder symptoms may not be included.3 Moreover, most of these studies are retrospective case studies with limited follow-up and focusing on the outcomes of surgical techniques to salvage AV fistula. There are no prospective studies quantifying critical distal ischemia after AV graft surgery.4–6
In this issue of CJASN, Allon et al.7 analyzed their prospectively collected data for incidence and risk factors associated with critical ischemia requiring intervention after AV access surgery, including both AV fistula and AV graft, as well as the feasibility of creating a new AV access without recurrence of distal ischemia. The incidence of severe distal ischemia was found to be 1.9% (28/1498 patients) over a 10-year study period. The most commonly associated risk factors noted in the study were female sex (odds ratio [OR], 3.64 [95% confidence interval (CI), 1.52 to 8.72]), peripheral arterial disease (OR, 6.28 [95% CI, 2.84 to 13.87]), and coronary artery disease (OR, 2.37 [95% CI, 1.08 to 5.23]), P < 0.001 on mutivariable logistic regression model analysis. With upper arm AV fistula or graft, distal ischemia was associated with female sex (OR, 2.95 [95% CI, 1.03 to 8.47]) and peripheral arterial disease (OR, 5.79 [95% CI, 2.26 to 14.83]) and a trend toward higher risk with AV graft compared with AV fistula (OR, 2.33 [95% CI, 0.87 to 6.26]).
The frequency of severe distal ischemia was lower with AV fistula both in the forearm and upper arm (0.2% and 0.9%, respectively) compared with AV graft (2.4% and 2.2%). The frequency was the highest with lower extremity AV graft (2.8%).
A total of 46% (13/28) patients received a second AV graft after ligation of their previous access. A larger proximal inflow artery was selected for the subsequent AV graft surgery. Only one of 13 (7.6%) patients developed significant ischemic symptoms after repeat AV graft surgery, requiring ligation at 6 weeks. The remaining 12 patients were able to maintain AV fistula patency without developing ischemic symptoms for a period of 3 months to 5 years.
The general dogma in the nephrology community is that ischemic symptoms are always as a result of a “steal syndrome.” In fact, the pathogenesis is complex and depends both on the preexisting vascular pathology and known associated risk factors. Assessment of preexisting peripheral arterial disease and collateral circulation (patent palmar arch) before access creation is important to reduce the risk of severe distal ischemia. Using the proximal ulnar or radial artery instead of brachial artery might reduce the risk of steal syndrome.2,8
Acute ischemic monomelic neuropathy is a rare catastrophic complication that usually presents in the immediate postoperative period within minutes to hours of creating an AV access. The new created AV access usually is ligated emergently because of the risk of permanent neurological sequelae.2
The presence of arteriosclerotic disease in the inflow artery is an important contributing factor for severe distal ischemia. The artery is evaluated with diagnostic arteriography, followed by balloon angioplasty for a localized stenotic lesion.1 In some cases, ligation of the access might be necessary in patients with diffuse arterial disease.
The severity of distal ischemic symptoms as categorized by the clinical staging (Figure 1) dictates the intervention plan. Patients with mild symptoms are often managed conservatively by reducing the blood flow during dialysis and wearing a hand warming glove. In general, AV access abandonment remains a last resort option to minimize tissue loss and salvage the extremity.
Figure 1.
Hand ischemia and dialysis vascular access. CAD, coronary artery disease; PAD, peripheral artery disease; PTA, percutaneous transluminal angioplasty.
In patients with severe ischemia, evaluation of the access flow using ultrasound is important to decide surgical approaches with the goal of salvaging the AV access. An access with high flow, defined as access flow of >2 L/min, is treated with flow reduction. Banding procedure, either surgically or endovascularly, can reduce the access flow to 1.0–1.2 L/min to improve distal circulation. In AV access with low to normal flow (0.8–1.0 L/min), various revascularization surgical techniques have been used successfully to improve distal circulation. The three most used surgical techniques are proximalization of arterial inflow, revision using distal inflow, and distal revision with interval ligation. Ligation of radial artery distal to AV anastomosis might be required in patients with radial cephalic AV fistula.9,10
In summary, severe distal ischemia is an uncommon complication that can hopefully be minimized with diligent preoperative assessment, particularly in patients who are at a high risk secondary to comorbidities, such as diabetes and peripheral arterial disease. It is possible to create a successful AV access after ligation of a previous access with significant steal symptoms. Ultimately, clinical symptoms and staging will dictate the management plan.
Acknowledgments
The authors wish to acknowledge Pallavi Prasad for creating the infographic. The content of this article reflects the personal experience and views of the authors and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or CJASN. Responsibility for the information and views expressed herein lies entirely with the authors.
Footnotes
See related article, “Vascular Access–Related Distal Ischemia Requiring Intervention: Frequency, Risk Factors, and Consequences,” on pages 1592–1598.
Disclosures
T.J. Vachharajani reports employment with John D. Dingell VA Medical Center; advisory or leadership roles on Editorial Boards for Indian Journal of Nephrology, Journal of Vascular Access, Kidney360, Kidney International Reports, and Seminars in Dialysis; role as an Associate Editor of Frontiers in Nephrology (Blood Purification Section); and other interests or relationships as Chair of Core Programs Committee for International Society of Nephrology and the International Board of Directors AVATAR Foundation, India. The remaining author has nothing to disclose.
Funding
None.
Author Contributions
Writing – original draft: Tze-Woei Tan, Tushar J. Vachharajani.
Writing – review & editing: Tze-Woei Tan, Tushar J. Vachharajani.
References
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