Dialysis access steal syndrome (dass) / distal hypoperfusion ischemic syndrome (dhis): case review and discussion of etiologies, diagnosis and treatment strategies in surgically imprecise and surgically non-viable cases

Authors:R. Hira, V. Ukirde*, A. Bansal, A. Gursale
Int J Biol Med Res. 2020; 11(4): 7161-7166  |  PDF File

Abstract

Introduction: Arteriovenous Fistulas are surgically created by connecting an artery and vein to provide vascular access for hemodialysis treatment. Once an AVF is made, the bulk of blood flow in the feeding artery (brachial, radial, ulnar) is diverted into the arterialized vein due to shunting of arterial blood into the low-pressure venous system resulting in a "physiological" or “silent” steal phenomenon. However, numerous factors such as peripheral arterial disease or excessive blood flow through the AVF may cause decreased flow distally resulting in Dialysis Access Steal Syndrome (DASS) or Distal Hypoperfusion Ischemic Syndrome (DHIS).It causes significant pain and discomfort but also can lead to tissue necrosis and the eventual loss of digits. Aims and Objectives: To understand various etiologies, diagnostic criteria and percutaneous interventions available for fistula preservation and fistula closure in surgically imprecise or surgically non-viable cases of DASS/DHIS. Materials and Methods: From August 2018 to November 2019, 3 patients presenting with DASS / DHIS were treated in our Department of Vascular Interventional Radiology in LTMG Hospital, Sion, Mumbai on an emergency or elective basis. Patient follow-up included clinical and ultrasound evaluation at 1 and 3 months after the procedures. Results & Conclusion: All 3 patients had autologous brachiocephalic fistulas. The fistula was either preserved and treated with a hybrid minimally invasive limited ligation endoluminal-assisted revision (MILLER) Procedure or closed using an Amplatzer Vascluar Plug (AVP). The case reports demonstrate that MILLER procedure was a highly precise treatment option to regulate the flow rate across an AVF by controlling AVF diameter using a balloon and also provided real time assessment of distal flow as compared to blind surgical banding/plication. The case reports also confirm that in case of fistula closure in surgically non-viable cases with AVP, no significant complications were observed such as plug migration, access revascularization or persistent ischemia.