DISCLOSURES ¥ Healthcare Professional Consultant & Trainer - CHALLENGES IN DIALYSIS ACCESS Abbott Vascular ¥ Speaker, Abbott Vascular Niren Angle, MD, RVT, FACS Vascular Surgery & Endovascular Therapy, EBCVT Lieutenant Colonel, USAF, MC Travis AFB, CA 1 2 STEAL SYNDROME COMPLICATIONS Grade of Ischemic Steal Central venous obstruction ¥ Grade 1: Discoloration without pain Ischemic steal syndrome ¥ Grade II : Pain during exercise or during dialysis Graft thrombosis ¥ Grade III : Ischemic pain at rest Pelle MT, Miller III OF. Arch Dermatol. 2002 Graft infection ¥ Grade IV :Tissue loss/necrosis/gangrene 3 4
STEAL SYNDROME ISCHEMIC STEAL CAUSES ¥ 68 year old Blood ßow restriction to the hand from arterial occlusive disease either proximal woman - ESRD or distal to the AV access anastomosis ¥ Liver transplant ¥ Inadequate Excess blood ßow through the AV Þstula superÞcial veins conduit (true steal) ¥ Right upper arm AV graft Lack of vascular (arterial) adaptation or collateral ßow reserve (ie ¥ Hand pain and atherosclerosis) to the increased ßow numbness 3-4 demand from the AV conduit weeks post-op 5 6 6 ISCHEMIC STEAL ¥ DRIL procedure ¥ Imp rovement but marginal ¥ Duplex with digit pressures ¥ Pat ent graft ¥ Normal velocities ¥ Digital pressures improved but Occlusion of the graft not normal (DBI 0.4) 7 8
THE DISEASED ARTERY ¥ 62 year old woman with previous left arm Þstula ¥ Hand pain for a year ¥ Repeated angioplasty of radial and ulcer arteries ¥ No resolution of pain ¥ Fistula deep 9 10 ASSESSING CAUSE OF ISCHEMIA RIGHT ARM BRACHIOCEPHALIC FISTULA ¥ Inßow issue? ¥ Outßow issue? ¥ Retrograde ßow? Ulnar artery ¥ Duplex vein mapping ¥ Arterial duplex ¥ Digital-brachial pressures 11 12
13 13 14 14 UPPER ARM ARTERIOVENOUS GRAFT ¥ 67 year old woman, non- diabetic ¥ Upper arm arteriovenous graft with venous outßow stenosis ¥ Right hand numbness ¥ Claw hand Given the runoff, I recommend simultaneous access and DRIL procedure to eliminate pressure drops across stenoses. 15 16
STEAL SYNDROME STEAL SYNDROME DRIL PROCEDURE 17 18 ¥ Persistent pain/ numbness ISCHEMIC STEAL particularly on RELIANCE ON OTHERS dialysis ¥ Palpable radial pulse ¥ Previous radio- cephalic Þstula ¥ Arteriogram (ligated) ¥ Diminutive ulnar artery ¥ Small or diseased ¥ Radial artery ulnar artery widely patent ¥ Duplex ¥ Proximal Þstula ÒremarkableÓ ¥ Hand steal - pain and numbness 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20
PREVIOUS CATHETER CENTR AL VENOUS OBSTRUCTION SVC PACEMAKER SYNDROME WIRES 21 22 MANIFESTATION OF VENOUS HYPERTENSION ¥ Arm swelling ¥ Low access ßows Duplex not useful for central venous obstruction ¥ High venous pressures CT venogram also of little use ¥ Prolonged bleeding on Angiogram of central venous system decannulation ¥ Facial swelling 23 24
CENTRAL VENOUS OCCLUSION 35 YEAR OLD MAN 25 26 CENTRAL VENOUS OCCLUSION 35 YEAR OLD MAN 27 28
MASSIVE RIGHT ARM & FACIAL SWELLING ! RIGHT ANTERIOR MINI-THORACOTOMY 42 YEAR OLD WOMAN Right axillary to SVC bypass with right upper arm AV graft 29 30 MASSIVE RIGHT ARM & FACIAL SWELLING ! MASSIVE RIGHT ARM & FACIAL SWELLING ! 42 YEAR OLD WOMAN 42 YEAR OLD WOMAN 31 32
SURGICAL OPTIONS FOR THE UNCROSSABLE CENTRAL VENOUS OCCLUSION 33 33 34 BRACHIOCEPHALIC VEIN OCCLUSION & BREAST SWELLING BRACHIOCEPHALIC VEIN OCCLUSION 35 36 36 36 36 36 36 36 36 36 36
CENTRAL VENOUS CATHETER BRACHIOCEPHALIC VEIN OCCLUSION & BREAST SWELLING 37 37 37 37 37 37 37 37 37 37 38 TIPS ¥ Arm swelling after access - central venous stenosis or obstruction till proven otherwise ¥ Signs of venous hypertension - ulcers, hyper pigmentation, numbness ¥ Catheter in place - must remove COMPLICATIONS? ¥ Venogram best option for diagnosis and treatment WHAT COMPLICATION? ¥ PTA alone versus stunting 39 40
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