Treatment of vascular steal syndrome
Date written: August 2011
Author: Christine Russell
GUIDELINES
No recommendations possible based on Level I or II evidence
SUGGESTIONS FOR CLINICAL CARE
(Suggestions based on level III and IV evidence)
Patients with symptoms of steal should be investigated for inflow stenosis.
There are a number of surgical procedures that can be used in the treatment of steal – Distal
revascularisation interval ligation (DRIL) procedure is probably the most widely used and
durable, with preservation of the access.
IMPLEMENTATION AND AUDIT
Audit the number of patients developing steal syndrome, interventions and patient outcomes.
BACKGROUND
Patients with steal phenomenon can present with paraesthesia, pain, ulceration and tissue loss. Some
degree of steal is common, for example, in a questionnaire of 120 haemodialysis patients, 50% of
patients with a brachio-cephalic AVF reported a cold hand compared with 12% of those with a radiocephalic AVF [1]. Dialysis Access Steal Syndrome (DASS) requiring intervention has an incidence of
around 4%, although 10-20% of patients with AV fistulas or grafts may suffer some degree of ischaemia
causing pain or paraesthesia [2]. DASS tends to present earlier in patients with an AV graft (AVG)
compared to those with a native AV fistula (AVF). For example the study by Lazarides et al [3] reported
an average time interval from access construction to occurrence of DASS of 2 days for AVG’s and 165
days for AVF’s.
DASS is usually due to one or more of the following factors;
Inflow stenosis – defined as stenosis within the arterial system, artery-graft anastomosis (graft
cases), artery-vein anastomosis (fistula cases) and juxta-anastomotic region (the first 2 cm
downstream from the arterial anastomosis)[4]
Retrograde flow – back flow into the artery distal to the arteriovenous anastomosis and into the
arteriovenous access [5]
Distal arteriopathy – result of generalized vascular calcification due to diabetes [6]
It may also rarely be due to a high flow fistula in patients with otherwise normal vessels [2].
A grading scheme has been proposed by Sidaway et al [7].
Grade 0: No steal
Grade 1: Mild - cool extremity with no symptoms but steal demonstrated by flow augmentation with
access occlusion.
Grade 2: Moderate - intermittent ischaemia only during dialysis/claudication
Grade 3: Severe - ischaemic pain at rest/tissue loss
Alternatively the leg ischaemia grade has been proposed by Tordoir et al [8].
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 1 of 16
Stage 1: Pale/blue and/or cold hand without pain
Stage 2: Pain during exercise and/or haemodialysis
Stage 3: Rest Pain
Stage 4: Ulcers/necrosis/gangrene
The aim of this guideline is to develop recommendations by reviewing the available evidence on the
management of steal syndrome.
SEARCH STRATEGY
Databases searched: MeSH terms and text words for dialysis and haemodialysis were combined with
MeSH terms and text words for vascular steal syndrome. The search was carried out in Medline (1950
– August Week 1, 2011). The Cochrane Renal Trials Register was also searched for trials not indexed
in Medline.
Date of search/es: August 2011.
WHAT IS THE EVIDENCE?
There are no randomised controlled trials relating to the diagnosis and treatment of DASS. The
available evidence relating to causes, diagnosis and treatment of DASS are largely limited to case
reports and retrospective reviews of case series within single centres. Furthermore, only a few studies
have made comparisons between treatments and even fewer have included a control group. This limits
the ability to make recommendations. In addition reported studies do not take into account the need for
temporary access and associated complications. A summary of key studies contributing to the evidence
is presented in Table 1.
Can DASS be predicted?
The identification of risk factors for DASS and is limited to retrospective reviews of generally small
patient numbers within single centres.
The following is a summary from the available evidence:
1. Risk factors for DASS
a. Independent risk factors for DASS include [9-13]:
Female gender (OR 1.77, P=0.040) [9]
Tobacco use (OR 2.0, P=0.048) [9]
Diabetes (OR 1.9, P=0.048) [9]; (OR 5, P=0.01) [10]
Peripheral vascular disease (OR 2.3, P=0.008) [9]
Coronary artery disease (OR 2.7, P<0.001) [9]
Hypertension (OR 2.8, P<0.001) [9]
Trend with increasing age [10]
b. Inadequate arterial inflow [14].
c. Distal arteriopathy in arteries supplying the hand [6].
d. Upper arm AVF compared to forearm. For example in the study by Morsy et al the incidence of
DASS was 4.3% in patients with upper arm AVFs compared to 1.8% in patients with forearm
AVFs [15]; while Odland et al report an incidence of 1% for forearm AVFs [16]. In the review by
Gupta et al [9] patients with DASS were more likely to have an upper arm fistula (OR 4.5,
P<0.001).
e. Upper arm AVF compared to grafts [13].
2. The digital brachial index (DBI) measured after the fistula has been placed has been shown to be
predictive of patients who develop DASS. In a prospective study of 109 haemodialysis patients, the
DBI was 0.74 +/- 0.26 (range 0.30-1.63) vs. 1.01 +/- 0.23 (range 0.45-1.76) with the AVF occluded
in those who did not develop DASS. In patients who subsequently developed DASS, the DBI was
0.44 +/- 0.13 (range 0.24-0.58) (P < 0.001 versus the asymptomatic group) and 0.95 +/- 0.24 (range
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 2 of 16
0.64-1.24) with the AVF occluded (P > 0.10 versus the asymptomatic group). A DBI threshold of
<0.6 predicted DASS symptoms with a sensitivity of 100%, specificity 59% and a PPV of 18%) [17].
In another study of 35 patients with DBI measured pre-op, day of surgery and at 1 month, there was
no decrease at one month, compared to immediately post-op. DBI in patients without steal dropped
from 0.9 to 0.7. In those with symptomatic steal, DBI dropped from 0.8 – 0.4 (P < 0.01). Using DBI
<0.6, sensitivity was 100% [18]. Tynan-Cuisinier et al recommend a DBI cut off of <0.45 as a more
accurate predictor of significant DASS [19].
3. In a case-control study of 40 patients the change in digital pressure (CDP) with the fistula
compressed was significantly greater in DASS patients compared to the controls. However, as a
predictive test, CDP was less accurate than either DBI or basal digital pressure both of which were
significantly lower in DASS patients compared to the controls [20].
4. Pre-operative digital pressures were examined prospectively in haemodialysis patients with brachial
artery fistulas and grafts [13]. Of the 72 patients, 14 (19%) developed DASS. Those without DASS
had significantly higher finger pressures of 151 +/- 27mmHg compared to those who developed
DASS who had finger pressures of 131 +/- 31mmHg (P < 0.03). There was however, no absolute
threshold identified below which DASS was inevitable.
5. Retrograde flow is a common phenomenon in the artery just distal to the anastomosis in 80-90% of
all AV fistulas [2]. In a cross sectional study of 24 haemodialysis patients 21/24 (88%) of radiocephalic AVF’s had diminished thumb pressures with a radio-cephalic AVF, which improved with
compression of both the fistula and also the radial artery below the anastomosis. However, only one
of these patients had symptoms of arterial insufficiency (i.e. DASS) [21].
In another study with mostly upper arm AVF’s or grafts showed 44% flow reversal, which again did
not correlate with symptoms [22]. This study also looked at the reduction of mean peak systolic
velocities in radial and ulnar arteries after arm vascular access formation, and showed no statistical
correlation with change in any hand symptoms. Baseline peak systolic flow or post-op reduction in
peak systolic velocity also did not correlate with development of steal symptoms in this study.
How should steal be treated?
The available evidence relating to the treatment of DASS is largely limited to case reports and case
series from single centres. There are no randomised control trials and limited prospective studies.
Furthermore most studies are limited to single procedures. Where multiple procedures have been
reviewed, the numbers of some procedures are small thereby limiting the ability to make meaningful
comparisons between treatment options. Table 1 presents a summary of studies that include
assessment of outcomes associated with treatment using the following procedures [23]:
Ligation of the AV fistula and loss of access.
Angioplasty to treat proximal artery disease.
Banding to increase resistance of the fistula.
Distal revascularisation, interval ligation, where the artery distal to the fistula is ligated and a
bypass graft is placed well above the fistula.
Revision using distal inflow (RUDI), where the fistula is ligated at its origin with a bypass created
from one or more distal forearm arteries.
Proximal arterial inflow (PAI) procedure where the fistula is ligated at its origin and a PTFE graft
is run from the more proximal brachial or axillary artery to the fistula.
1. Ligation of the AV fistula. This usually results in loss of symptoms, but also the loss of the access
and therefore limited to severe cases of DASS [9, 11, 13, 24]. In the case of radio-cephalic end-toside fistulas, the radial artery can be ligated below the anastomosis if there is reversed flow.
2. In the prospective case series reported by Asif et al [14], complete arteriography was performed on
12 patients with DASS symptoms. Arterial stenosis was identified in 10 patients 8 of whom were
treated with angioplasty resulting in resolution of symptoms and access preservation in all 8
patients. The remaining patients were treated using surgical interventions.
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 3 of 16
3. The DRIL procedure was first described in 1988 by Schanzer [25]. This has been shown to be the
best from a number of different configurations on the basis of theoretical flow modelling. An untapered 6-mm prosthetic brachial-axillary access was selected as the prototype configuration, and
the theoretical effect of six access modifications on forearm flow was analysed. This showed that
theoretically, DRIL was the best procedure, followed by DR without ligation, and more proximal take
off procedure. [26]. One group has measured pressures at various points both before and after
DRIL and concluded that the improvement was due to a higher pressure at the point where the
blood supply to the hand and to the fistula divide, being higher up the arm [27]. This would explain
why proximalisation of the input also works.
The DRIL procedure is the most reported albeit all retrospective studies (refer to Table 1) [3, 9, 1113, 24, 28-32]. Comparison across studies is limited due to the incomplete reporting of the severity
of DASS of the included patients. The largest study by Huber at al [28] of 77 patients with
moderate or severe ischaemia. Of these 61 were treated with DRIL and 16 required fistula ligation.
Of the patients who underwent the DRIL procedure, the access retention rate was 100%, symptom
relief 78% of patients and bypass patency rates of 77, 74 and 71% at 1, 3 and 5 years respectively.
These rates are typical for all of the DRIL studies (refer to Table 1) with lower success rates being
associated with more severe cases of DASS.
Where reported, patient survival following intervention is generally poor [12, 28, 30, 33] reflecting
the overall poor outcomes for patients affected by DASS associated with a high prevalence of
comorbidities.
4. Studies reporting results of banding to reduce the flow through the fistula are generally limited to
small retrospective reviews [9, 11, 13, 15, 16, 24, 34-39]. The prime problem associated with
banding is the inability to regulate access flow to improve perfusion of the hand while reducing the
risk of thrombosis. As a consequence, banding is often associated with lower success rates in
terms of both symptom control and maintenance of the access. A number of strategies have been
used to attempt to get the balance correct:
a. Using a photoplethysmograph (PPG) on digits to assess degree of banding, however this has
only been reported for 2 patients [16, 39].
b. Use of a digital pulse volume recording, however this has only been reported in a DRIL study
[30].
c. Intra-operative DBI which is lower in those who develop DASS, but not different between
mild/severe steal. Tynan-Cuisinier et al suggest that 50% of patients with asymptomatic DASS
had an intraoperative DBI of <0.6 whereas 25% of patients with asymptomatic DASS had a DBI
<0.45 [19]
d. Using clips.
e. Use of a Goretex cuff [40].
f. Using an intra-vascular balloon to tie the ligature around to get standardised size (4 or 5mm)
[34, 36].
5. The RUDI procedure, which avoids ligation of the artery, has been reported in only 3 studies [9, 41,
42]. These report good success rates in terms of symptom control and maintenance of the access,
however the combined studies include only 15 patients.
6. The PAI procedure, which also avoids ligation of the artery, has been reported in one study of 30
patients with severe DASS [33]. Good success rates in terms of symptom control (84% of patients)
and AV access patency rates (87% at 6 months and 67% at 36 months).
7. Use of tapered grafts – 4mm versus 7mm. 4mm graft shows a 28% reduction in flow at pressure of
100mmHg [43]
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 4 of 16
SUMMARY OF THE EVIDENCE
There are no randomised controlled trials and only a small number of prospective studies examining the
occurrence, diagnosis and treatment of DASS. Most studies are retrospective reviews of case series
from single centres with limited controls or comparison of interventions.
Can steal be predicted?
Steal is more likely in diabetics, older patients and those with an upper arm fistula or graft, but there are
no clear predictive factors.
Can steal be diagnosed?
Retrograde flow is common in patients with upper extremity AVF’s and AVF’s, however only a small
proportion develop symptomatic DASS. A DBI of <0.6 after formation of a fistula is very likely to be
associated with symptomatic steal.
How should steal be treated?
There are a number of options which should be tailored to the individual patient. An assessment of the
arterial inflow should be performed and arterial stenosis treated. Options then include:
Ligation of AVF
Ligation of distal radial artery if a radio-cephalic fistula
DRIL procedure
PAI procedure
RUDI procedure
Banding of the AV fistula
Use of a tapered graft
WHAT DO THE OTHER GUIDELINES SAY?
Kidney Disease Outcomes Quality Initiative: Guideline 16. [44]
Managing Potential Ischemia in a Limb Bearing an AV Access. All patients, particularly those in
high-risk groups, should be monitored for the development of limb ischemia following AV access
construction.
A. Patients in high-risk groups (diabetic, elderly, those with multiple access attempts in an extremity)
should be monitored closely for the first 24 hours postoperatively. Monitoring should include:
(Opinion)
1. Subjective assessment of complaints, including sensations of coldness, numbness, tingling, and
impairment of motor function (not limited by postoperative pain)
2. Objective assessment of skin temperature, gross sensation, and movement and distal arterial
pulses in comparison to the contralateral side
3. Teaching patients to immediately report any coldness, loss of motion, or significant reduction in
sensation
B. Patients with an established fistula should be assessed monthly. The following are recommended as
part of this assessment: (Opinion)
1. Obtaining an interval history of increased distal coldness or distal pain during dialysis,
decreased sensation, weakness or other reduction in function, or skin changes
2. Confirming any abnormalities by physical examination.
Patients with new findings suggestive of ischemia (A.3 above) should be referred to a vascular
access surgeon emergently. Reduced skin temperature, as an isolated finding, requires followup observation but no emergent intervention. (Opinion)
UK Renal Association: [45]
Guideline 6.3. Treatment of ischemia related to arteriovenous fistulae or grafts. We suggest that the
development of peripheral ischaemia related to arteriovenous fistulae or grafts requires early review by
the vascular access surgeon to allow proactive intervention to prevent the onset of gangrene or need
for amputation. (2B)
Canadian Society of Nephrology: [46]
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 5 of 16
Guideline 3.5.1. Monitor all patients, particularly those in high-risk groups, for the development of limb
ischemia following AV access construction (opinion).
Europeon Best Practice Guidelines: [47]
Guideline 9.1. Access-induced ischaemia should be detected by clinical investigation and the cause
should be identified by both non-invasive imaging methods and angiography (Evidence level III).
Guideline 9.2. Enhancement of arterial inflow, access flow reduction and/or distal revascularization
procedures are the therapeutic options. When the above methods fail, access ligation should be
considered (Evidence level II).
International Guidelines: No recommendation.
SUGGESTIONS FOR FUTURE RESEARCH
Randomised controlled trials are unlikely to take place, though it would be interesting to compare
proximalisation of inflow and the DRIL procedure.
CONFLICT OF INTEREST
Christine Russell has no relevant financial affiliations that would cause a conflict of interest according to
the conflict of interest statement set down by KHA-CARI.
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 6 of 16
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
van Hoek F, Scheltinga MR, Kouwenberg I et al. Steal in hemodialysis patients
depends on type of vascular access. European Journal of Vascular & Endovascular
Surgery. 2006; 32: 710-7.
Suding PN and Wilson SE. Strategies for management of ischemic steal syndrome.
Seminars in Vascular Surgery. 2007; 20: 184-8.
Lazarides MK, Staramos DN, Kopadis G et al. Onset of arterial 'steal' following
proximal angioaccess: immediate and delayed types. Nephrology Dialysis
Transplantation. 2003; 18: 2387-90.
Asif A, Gadalean FN, Merrill D et al. Inflow stenosis in arteriovenous fistulas and
grafts: a multicenter, prospective study. Kidney International. 2005; 67: 1986-92.
Mickley V. Steal syndrome—strategies to preserve vascular access and extremity.
Nephrology Dialysis Transplantation. 2008; 23: 19-24.
Leon C and Asif A. Arteriovenous access and hand pain: the distal hypoperfusion
ischemic syndrome. Clinical Journal of The American Society of Nephrology:
CJASN. 2007; 2: 175-83.
Sidawy AN, Gray R, Besarab A et al. Recommended standards for reports dealing
with arteriovenous hemodialysis accesses. Journal of Vascular Surgery. 2002; 35:
603-10.
Tordoir JHM, Dammers R, and van der Sande FM. Upper extremity ischemia and
hemodialysis vascular access. European Journal of Vascular & Endovascular
Surgery. 2004; 27: 1-5.
Gupta NMDa, Yuo THMDb, Konig GIVMSb et al. Treatment strategies of arterial
steal after arteriovenous access. Journal of Vascular Surgery. 2011; 54: 162-167.
Davidson D, Louridas G, Guzman R et al. Steal syndrome complicating upper
extremity hemoaccess procedures: incidence and risk factors. Canadian Journal of
Surgery. 2003; 46: 408-12.
Mwipatayi BP, Bowles T, Balakrishnan S et al. Ischemic steal syndrome: a case
series and review of current management. [Review]. Current Surgery. 2006; 63:
130-5.
Knox RC, Berman SS, Hughes JD et al. Distal revascularization-interval ligation: a
durable and effective treatment for ischemic steal syndrome after hemodialysis
access. Journal of Vascular Surgery. 2002; 36: 250-5; discussion 256.
Valentine RJ, Bouch CW, Scott DJ et al. Do preoperative finger pressures predict
early arterial steal in hemodialysis access patients? A prospective analysis. Journal
of Vascular Surgery. 2002; 36: 351-6.
Asif A, Leon C, Merrill D et al. Arterial steal syndrome: a modest proposal for an old
paradigm. American Journal of Kidney Diseases. 2006; 48: 88-97.
Morsy AH, Kulbaski M, Chen C et al. Incidence and characteristics of patients with
hand ischemia after a hemodialysis access procedure. Journal of Surgical
Research. 1998; 74: 8-10.
Odland MD, Kelly PH, Ney AL et al. Management of dialysis-associated steal
syndrome complicating upper extremity arteriovenous fistulas: use of intraoperative
digital photoplethysmography. Surgery. 1991; 110: 664-669.
Goff CD, Sato DT, Bloch PH et al. Steal syndrome complicating hemodialysis
access procedures: can it be predicted? Annals of Vascular Surgery. 2000; 14: 13844.
Papasavas PK, Reifsnyder T, Birdas TJ et al. Prediction of arteriovenous access
steal syndrome utilizing digital pressure measurements. Vascular & Endovascular
Surgery. 2003; 37: 179-84.
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 7 of 16
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
Tynan-Cuisinier GS and Berman SS. Strategies for predicting and treating access
induced ischemic steal syndrome. European Journal of Vascular & Endovascular
Surgery. 2006; 32: 309-15.
Schanzer A, Nguyen LL, Owens CD et al. Use of digital pressure measurements for
the diagnosis of AV access-induced hand ischemia. Vascular Medicine. 2006; 11:
227-31.
Duncan H, Ferguson L, and Faris I. Incidence of the radial steal syndrome in
patients with Brescia fistula for hemodialysis: its clinical significance. Journal of
Vascular Surgery. 1986; 4: 144-7.
Goldfeld M, Koifman B, Loberant N et al. Distal arterial flow in patients undergoing
upper extremity dialysis shunting: a prospective study using doppler sonography.
American Journal of Roentgenology. 2000; 175: 513-6.
Zamani P, Kaufman J, and Kinlay S. Ischemic steal syndrome following arm
arteriovenous fistula for hemodialysis. Vascular Medicine. 2009; 14: 371-6.
Haimov M, Schanzer H, and Skladani M. Pathogenesis and management of upperextremity ischemia following angioaccess surgery. Blood Purification. 1996; 14:
350-4.
Schanzer H, Schwartz M, Harrington E et al. Treatment of ischemia due to "steal"
by arteriovenous fistula with distal artery ligation and revascularization. Journal of
Vascular Surgery. 1988; 7: 770-3.
Gradman WS and Pozrikidis C. Analysis of options for mitigating hemodialysis
access-related ischemic steal phenomena. Annals of Vascular Surgery. 2004; 18:
59-65.
Illig KA, Surowiec S, Shortell CK et al. Hemodynamics of distal revascularizationinterval ligation. Annals of Vascular Surgery. 2005; 19: 199-207.
Huber TS, Brown MP, Seeger JM et al. Midterm outcome after the distal
revascularization and interval ligation (DRIL) procedure. Journal of Vascular
Surgery. 2008; 48: 926-32; discussion 932-3.
Yu SH, Cook PR, Canty TG et al. Hemodialysis-related steal syndrome: predictive
factors and response to treatment with the distal revascularization-interval ligation
procedure. Annals of Vascular Surgery. 2008; 22: 210-4.
Walz P, Ladowski JS, and Hines A. Distal revascularization and interval ligation
(DRIL) procedure for the treatment of ischemic steal syndrome after arm
arteriovenous fistula. Annals of Vascular Surgery. 2007; 21: 468-73.
Sessa C, Riehl G, Porcu P et al. Treatment of hand ischemia following angioaccess
surgery using the distal revascularization interval-ligation technique with
preservation of vascular access: description of an 18-case series. Annals of
Vascular Surgery. 2004; 18: 685-94.
Berman SS, Gentile AT, Glickman MH et al. Distal revascularization-interval ligation
for limb salvage and maintenance of dialysis access in ischemic steal syndrome.
Journal of Vascular Surgery. 1997; 26: 393-402; discussion 402-4.
Zanow J, Kruger U, and Scholz H. Proximalization of the arterial inflow: a new
technique to treat access-related ischemia. Journal of Vascular Surgery. 2006; 43:
1216-21; discussion 1221.
Miller GA, Goel N, Friedman A et al. The MILLER banding procedure is an effective
method for treating dialysis-associated steal syndrome. Kidney International. 2010;
77: 359-66.
Thermann F, Wollert U, Dralle H et al. Dialysis shunt-associated steal syndrome
with autogenous hemodialysis accesses: proposal for a new classification based on
clinical results. World Journal of Surgery. 2008; 32: 2309-15.
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 8 of 16
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
Goel N, Miller GA, Jotwani MC et al. Minimally Invasive Limited Ligation
Endoluminal-assisted Revision (MILLER) for treatment of dialysis accessassociated steal syndrome. Kidney international. 2006; 70: 765-70.
Schneider CG, Gawad KA, Strate T et al. T-banding: a technique for flow reduction
of a hyperfunctioning arteriovenous fistula. Journal of Vascular Surgery. 2006; 43:
402-5.
DeCaprio JD, Valentine RJ, Kakish HB et al. Steal syndrome complicating
hemodialysis access. Cardiovascular Surgery. 1997; 5: 648-53.
Mattson WJ. Recognition and treatment of vascular steal secondary to hemodialysis
prostheses. American Journal of Surgery. 1987; 154: 198-201.
Papalois VE, Haritopoulos KN, Labruzzo C et al. Reversal of steal syndrome
following creation of arteriovenous fistula by banding with a Gore-Tex cuff: a new
technique. International Surgery. 2001; 86: 210-2.
Callaghan CJ, Mallik M, Sivaprakasam R et al. Treatment of dialysis accessassociated steal syndrome with the "revision using distal inflow" technique. Journal
of Vascular Access. 2011; 12: 52-6.
Minion DJ, Moore E, and Endean E. Revision using distal inflow: a novel approach
to dialysis-associated steal syndrome. Annals of Vascular Surgery. 2005; 19: 625-8.
Krueger U, Huhle A, Krys K et al. Effect of tapered grafts on hemodynamics and
flow rate in dialysis access grafts. Artificial Organs. 2004; 28: 623-8.
National Kidney Foundation. III. NKF-K/DOQI Clinical Practice Guidelines for
Vascular Access: update 2000. American journal of kidney diseases. 2001; 37:
S137-81.
Fluk R and Kumwenda MJ, Treatment of ischemia related to arteriovenous fistulae
or grafts. Guideline 6.3. , in Vascular access for haemodialysis. 2011, UK Renal
Association.
Ethier JH, Lindsay RM, Barre PE et al. Clinical practice guidelines for vascular
access. Canadian Society pf Nephrology. Journal of the American Society of
Nephrology. 1999; 10 Suppl 13: S297-305.
Tordoir J, Canaud B, Haage P et al. EBPG on Vascular Access. Nephrology
Dialysis Transplantation. 2007; 22: ii88-117.
____________________________________________________________________________________________________________
Vascular Access
July 2012
Page 9 of 16
APPENDICES
Table 1. Characteristics of included studies
Study ID
N
Study design
Participants
Procedure
Gupta (2011) [9]
114
(DASS)
100
(control)
Retrospective
review,
case/control
All patients who
underwent corrective
procedure for DASS.
Controls consecutive
AV access patients
from contemporary time
period.
Ligation (n=27)
Not stated
Banding (n=22)
DRIL (n=21)
Improve inflow
(n=9)
RUDI (n=4)
PAI (n=3)
Revascularisation
(n=1)
Callaghan (2011)
[41]
7
Retrospective
review
RUDI
Miller (2010) [34]
183
(114
with
DASS)
Case series
All brachiocephalic or
brachiobasilic AVFs
with Grade 3 DASS
Patients with DASS or
high flow access.
Huber (2008) [28]
61
Retrospective
review
All moderate or severe
ischaemia (Grade 2 or
3).
DRIL
Banding
(MILLER)
Follow up
Median 19
months
(range 7-36)
Mean 11
months
(range,
0.25-37)
Mean 12
months
(range, 066)
Comments and results
Risk factors for DASS: Female gender (P=0.040); tobacco use (P=0.048);
diabetes (P=0.016); Hypertension (P<0.001); peripheral vascular disease
(P=0.008); CAD (P<0.001).
Patients with DASS more likely to have upper arm fistula than those without
steal (P<0.001).
Success rate (resolution of DASS and preservation of AV access):
o Ligation 0% (100% DASS control).
o Banding 38% (19% fistula thrombosis, 48% persistence of
DASS)
o DRIL 80% (90% control of DASS, 10% loss of AV)
o RUDI 100%
o PAI 100%
o Revascularisation 100%
DASS symptoms resolved in 100% of patients.
3 fistulas (43%) failed.
Incidence of DASS and high flow requiring treatment estimated at around
6%.
Technical banding success in 98% of attempts.
DASS complete symptoms relief – 89% (first banding), 96% (one or more
bandings).
Band related thrombectomies required in 4.4% of DASS patients.
Primary access patency – 52% at 3 months in DASS patients.
Secondary access patency – 90% at 24 months.
Incidence of severe hand access related ischaemia – 6%
77 patients identified of which 61 treated with DRIL and 16 with access
ligation
100% access preservation.
Primary DRIL patency rates
o 1 year - 77±8%
o 3 years - 74±9%
o 5 years - 71±9%
Symptom relief – 78%
Patient survival
o 1 year – 71±6%
o 3 years – 59±7%
o 5 years - 33±9%
___________________________________________________________________________________________________________________________________________________________________
Vascular Access
July 2012
Page 10 of 16
Study ID
N
Study design
Participants
Procedure
Follow up
Thermann (2008)
[35]
63
Retrospective
review
All patients treated for
DASS.
Conservative
Banding
PAI
Yu (2008) [29]
24
Retrospective
review
All patients undergoing
intervention for DASS
DRIL
Median 50
months
Walz (2007) [30]
33
Retrospective
review
All patients undergoing
intervention for DASS
DRIL
Average
10.5 months
Mwipatayi (2006)
[11]
18
Retrospective
review
All patients with clinical
signs of steal confirmed
with PPG.
DRIL (12)
Ligation (5)
Banding (1)
Angioplasty (1)
Median 4
months
(range 1 to
12 months)
Comments and results
Overall incidence of DASS – 5.5%
Conservative therapy used for 8 patients with mild symptoms.
Treatment success rate –
o Banding - 100% for patients without lesions, 94% primary
patency at 1 year, early thrombosis in 1 patient.
o Banding - 0% for patients with lesions <1 cm and >1cm.
o PAI - 94% for patients with lesions <1cm (not used for other
patient groups), 65% patency at 18 mths.
Incidence of significant DASS estimated at 2%.
Demographics
o Female - 58%
o Diabetes – 92%
o Hypertension – 88%
Patency of DRIL - 95%
Maintenance of access – 87%
Symptom control – 96%
Mortality – 58%
Incidence of DASS requiring DRIL – 5.4%
Demographics
o Female – 63.9%
o CAD – 69.4%
o Diabetes – 33.3%
o Hypertension – 88%
o Tobacco use – 60%
DRIL patency
o 6 months – 80%
o 12 months – 51%
Symptoms relief
o Relief range from 100% to 66.7% (necrosis)
o Complete resolution of all symptoms – 66.7%
Symptom development after DRIL
o Range from 5.6% to 0% (necrosis, gangrene)
Patient survival
o 1 year - 70%
o 2 years – 36%
Symptom improvement with DRIL
o Resolved - 33.3%.
o Improved – 50%
o No improvement – 16.7%
All DRILL were patent at follow up.
All ligated patients improved.
Banded patient’s graft thrombosed.
___________________________________________________________________________________________________________________________________________________________________
Vascular Access
July 2012
Page 11 of 16
Study ID
N
Study design
Participants
Procedure
Follow up
Goel (2006) [36]
16
Case series
All patients with DASS
requiring intervention.
Banding
(MILLER)
Incidence of DASS requiring intervention estimated at 1.3%
Symptom improvement – 100%
Working access within follow up – 100%
Asif (2006) [14]
12
Prospective
case series
All patients with DASS
symptoms.
Angioplasty
Surgical
intervention
Mean 3
months
(maximum
11 months)
Mean 8.3
months
(range, 3-18
months)
Zanow (2006)
[33]
30
Prospective
case series
All patients with severe
DASS and AVF and
AVG flow rates <800
ml/min and <1000
ml/min respectively.
PAI
Mean 26.1
months
(range, 3-61
months)
Schneider (2006)
[37]
22 (6
with
DASS)
15
(DASS)
25
(control)
Case series
Patients with high shunt
flow treated with Tband
Consecutive patients
with symptomatic
DASS.
Consecutive patients
without DASS.
Banding (T-band) 3 months
Incidence of DASS requiring intervention – 3.3%
PAI undertaken in 23% of patients with DASS.
Significant improvement in DASS symptoms - 84%
Primary patency rates
o 6 months - 87±6%
o 12 months – 67±11%
Secondary patency rates
o 12 months – 90±5%
o 24 months - 78±8%
Patient survival
o 12 months - 97±3%
o 36 months - 60±11%
DASS symptom relief – 5 out of 6 (83%)
Primary patency at 3 months – 90%
Secondary patency at 3 months – 100%
Mean BDP (30 vs 102 mmHg) and DBI (0.3 vs 0.8) significantly lower in
DASS patients (P<0.001).
Mean CDP (85 vs 40 mmHg) was significantly higher in DASS patients
(P<0.001).
BDP threshold 60 mmHg – sens, 100%, spec. 87%
DBI threshold 0.4 – sens 92%, spec.96%.
CDP 80 mmHg increase – sens. 78%, spec. 87%
Schanzer (2006)
[20]
Case control
NA
Comments and results
Incidence of patients with DASS symptoms – 3.2%
Complete arteriography performed.
Arterial stenosis identified in 10 patients.
Angioplasty performed on 8 and surgical intervention on 4.
Angioplasty – 100% resolution of symptoms and 100% access
preservation.
Surgical intervention – 100% resolution of symptoms, 1 access required
ligation.
___________________________________________________________________________________________________________________________________________________________________
Vascular Access
July 2012
Page 12 of 16
Study ID
N
Study design
Participants
Procedure
Follow up
Tynan-Cuisner
(2006) [19]
100
Prospective
cohort
Consecutive patients
receiving new AV
access fistulas and
grafts.
NA
12 months
Minion (2005)
[42]
4
Case series
Patients with DASS
RUDI
4 months
Sessa (2004)
[31]
18
Case series
Patients with severe
DASS
DRIL
Davidson (2003)
[10]
20
Retrospective
review
All upper limb AVF and
AVG patients (n=217)
Mean 16
months
(range, 5-48
months)
NA
Lazarides (2003)
[3]
28
Retrospective
review
All patients with ―limb
threatening‖ DASS
requiring surgical
correction.
DRIL
Not stated
Comments and results
DBI threshold 0.6
o Sensitivity – 94%
o Specificity - 43%
o PPV – 21%
o NPV – 98%
DBI threshold 0.45
o Sensitivity – 80%
o Specificity - 70%
o PPV – 30%
o NPV – 97%
Complete symptom relief in 3 of the 4 patients.
Partial symptom relief in 1 patient.
No patency rates or maintenance of access reported.
Complete symptom relief – 73%.
Significant improvement in symptoms – 27%
Overall incidence of DASS – 6.2%.
Significant risk factors - univariate
o Diabetes
o AVG vs AVF
o Female vs male
o Proximal procedure
o CAD or CVD
Multivariate analysis
o Diabetes
o Aboriginal race
Estimated incidence of ―limb threatening‖ DASS:
o Overall – 4.2%
o AVG – 5.2%
o AVF – 3.4%
Time interval from initial access to DASS:
o AVG 2 days (range, 1-30)
o AVF 165 days (range, 60-720), P<0.001
Immediate, significant or complete symptom improvement – 100%
Thrombosis during study period – 25%
Symptom free cumulative patency:
o 1 year – 69%
o 2 years – 54%
___________________________________________________________________________________________________________________________________________________________________
Vascular Access
July 2012
Page 13 of 16
Study ID
N
Study design
Participants
Papasavas
(2003) [18]
35
Prospective
cohort
Valentine (2002)
[13]
72
Prospective
cohort
ESRD patients
requiring upper
extremity
haemodialysis. DBI
measured
preoperatively,
immediately after
surgery and at followup.
Haemodialysis patients
with brachial artery
fistulas and grafts.
Knox (2002) [12]
52
Retrospective
review
Goldfeld (2000)
[22]
18
Prospective
cohort
Procedure
Follow up
Comments and results
1.2 months
median for
DBI, 12
months for
DASS
symptoms.
Incidence of DASS – 6 (17%).
DBI values
o DASS – 0.8 (pre) drop to 0.4 (post)
o NonDASS – 0.9 (pre) drop to 0.7 (post)
DBI threshold <0.6 immediately post surgery (i.e. same day)
o Sensitivity – 100%
o Specificity – 76%
o PPV – 46%
PTA
DRIL
Banding
Ligation
Not stated
Incidence of DASS 19%
DASS developed in 50% of AVFs and 13% of AVGs (P<0.001)
DASS patients compared to non DASS had a higher proportion:
o CAD – P=0.005
o AVF – P=0.009
All patients who
underwent DRIL
procedure.
DRIL
Mean 16
months
(range, 1-67
months)
Patients scheduled for
upper extremity
proximal arteriovenous
fistulas.
NA
2-4 weeks
6 months
DASS incidence
o Overall - 4.6%.
o Female – 6.5%.
o Male – 2.8%.
DASS symptom alleviation – 90%.
Access ligation was required in 3 patients (6%).
Primary patency of DRIL
o 12 months - 86%
o 48 months - 80%
Patient survival
o 12 months - 86%
o 48 months - 56%
Six (33%) of patients had hand symptoms within 6 weeks of surgery.
Reverse flow observed in 8 (44%) of patients. Only one symptomatic
patient had reverse flow.
There was no statistical correlation between occurrence of symptoms and
absolute peak systolic velocity or the magnitude of the decrease in peak
systolic velocity after surgery.
___________________________________________________________________________________________________________________________________________________________________
Vascular Access
July 2012
Page 14 of 16
Study ID
N
Study design
Participants
Procedure
Follow up
Goff (2000) [17]
31
(DASS)
24
(control)
109
(prospe
ctive)
1.
Retrospective
review.
Patients with DASS
requiring surgical
intervention.
Control group – random
sample without DASS.
Both groups had
undergone
postoperative DBI.
Prospective study –
patients undergoing
AVFsurgery.
NA
Not stated
DBI values - retrospective
o Control – 0.71±0.23 vs 0.91±0.21 (AVF occluded)
o DASS – 0.34±0.23 vs 0.78±0.21 (AVF occluded)
DBI values – prospective (DASS incidence n=6, 5.5%)
o Asymptomatic – 0.74±0.26 vs 1.01±0.23 (AVF occluded)
o DASS – 0.44±0.13 vs 0.95±0.24 (AVF occluded)
Threshold DBI value of 0.6:
o Sensitivity – 100%
o Specificity – 59%
o PPV – 18%
o NPV – 100%
Morsy (1998) [15]
15
Retrospective
review
All patients diagnosed
with DASS
Conservative
Banding
Not stated
DeCaprio (1997)
[38]
18
Retrospective
review
All patients with
symptomatic DASS.
Banding (n=11)
Not stated
Berman (1996)
[32]
21
Retrospective
review
All patients who
underwent DRIL
procedure for DASS
DRIL
Mean 8
months
(range 1 to
31 months)
Haimov (1996)
[24]
34
Retrospective
review
Patients with severe
DASS.
Banding
DRIL
Ligation
Incidence of DASS
o 4.3% AVG
o 1.8% AVF
Clinical characteristics
o Diabetes – 66.4%
o Chronic hypertension – 80%
o Peripheral arterial disease – 93.3%
o Coronary artery disease – 53.3%
DASS incidence - 1.8%
Symptoms resolved in 10 of 11 patients.
Graft patency after 1 week was maintained in only 1 patient.
Incidence of DASS requiring DRIL – 2%
Patient mortality over follow up – 29%
Patency rate
o DRILL 18 months – 100%
o Access 18 months – 94%
Separately report on 29 patients subject to banding of which successful
treatment of DASS and maintenance of the access was achieved in 15
(52%)
Banding – 4 patients
o 3 grafts thrombosed within 3 months
o 1 – open access at 1 month with partial symptom relief.
Ligation – 23 patients
o DASS improvement after surgery – 100%
o Complete resolution of DASS – 83%
o AVF patency 73% (1 year), 45.5% (2 years)
o Bypass patency 95.6% (1 and 2 years)
2. Prospective
Comments and results
___________________________________________________________________________________________________________________________________________________________________
Vascular Access
July 2012
Page 15 of 16
Study ID
N
Study design
Participants
Procedure
Follow up
Odland (1991)
[16]
27
Retrospective
review
All patients diagnosed
with DASS
Banding
18 months
Mattson (1987)
[39]
Duncan (1986)
[21]
2
Case report
Patients with DASS
Banding
Not stated
24
Cross
sectional
Haemodialysis patients
NA
NA
Comments and results
Incidence of DASS
o Overall – 5.1%.
o Radiocephalic – 1.1%
o Forearm loop arteriovenous grafts – 7.0%
o Proximal arteriovenous loop grafts – 8.6%
Fistula ligation used in 9 patients with severe DASS.
Intraoperative PPG was used to guide the degree of narrowing to achieve a
digital blood pressure of 50 mm Hg.
DASS symptoms resolved in all 16 patients banded.
Graft patency
o 6 months - 62.5%
o 12 months - 38.5%
Used PPG to guide degree of banding.
Effective symptom control and lasting access (qualitative reporting only).
A radial steal was indicated by an increase in the thumb/brachial ratio from
0.61 to 0.85 (P<0.001) in 21 of 24 fistulas.
Only 1 patient had DASS symptoms.
___________________________________________________________________________________________________________________________________________________________________
Vascular Access
July 2012
Page 16 of 16