Nephrol Dial Transplant (1999) 14: 2777-2778
© 1999 European Renal Association-European Dialysis and Transplant Association
Letters
Vascular Steal Syndrome
Nephrology Service, ASS 4 `Medio Friuli', Ospedale Civile di Cividale 1 Institute of Radiology, Ospedale Civile di Udine, Cividale del Friuli and Udine, Italy
Sir,
We recently read the interesting report of A. M. Miles about the vascular steal syndrome [1]. Ligation of the distal radial artery limb of a side-to-side radiocephalic fistula, various techniques of fistula banding, ligation of the arterial limb and placement of an interposition graft are mentioned in the treatment of vascular steal. We have recently successfully employed a noninvasive method to treat this syndrome.
In April 1997, a left latero-lateral radiocephalic arteriovenous fistula with vein terminalization was performed in a 65-year-old uraemic male, and dialytic treatment was started. The primary nephropathy was unknown. Moderate hypertension with diffuse atherosclerosis and mild, diet-treated type 2 diabetes were present. In July of the same year malfunction of the fistula led us to perform angiography, which showed tight stenosis of the vein near the AV anastomosis and an arterial stenosis greater than 50–60%. Dilatation of the venous stenosis was performed. In November angiography was repeated, showing a worsening of the arterial stenosis to 80%.
Two months later ischaemic lesions appeared at the extremities of the left first and second fingers (i.e. small ulcerative lesions with signs of re-epithelialization); after 4 weeks a new ulcerative lesion appeared at the metacarpo-phalangeal junction of the second finger. Eco-colour Doppler showed reduced distal flow of the radial artery with reversal of blood flow from the digital and palmar arches. In June 1998, the cutaneous lesions worsened, developing into severe trophic ulcerations of the fingers and purulent secretion from the dorsal ulcer, despite conservative therapy.
Four months later, at the end of October, a third angiographic examination demonstrated severe artery stenosis (>90%), treated successfully with angioplasty (at 2 and 3 mm in diameter). The angiogram revealed an important reduction of the arterial inflow when the fistula was functioning (Figure 1
), and good distal vascularization when the fistula was manually occluded (Figure 2).
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In order to preserve the vascular access the patient was treated with acenocumarol (3 mg/day, to achieve an INR between 1.5 and 2.0), and application of a compressive bandage on the anastomosis during the interdialytic period was used to increase blood flow to the fingers. Within 15 days the cutaneous lesions had healed (Figure 3
), and the fistula continued to function well. Currently, after 4 months, fistula blood flow during dialysis exceeds 300 ml/min and the condition of the left hand remains good.
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In conclusion, partial compression of the anastomosis in the interdialytic period associated with anticoagulation therapy to reduce the risk of thrombosis represents a simple noninvasive therapy of the vascular steal syndrome and should be considered before opting for surgical intervention.
References
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Miles AM. Vascular steal syndrome and ischaemic monomelic neuropathy: two variants of upper limb ischaemia after hemodialysis vascular access surgery. Nephrol Dial Transplant 1999; 14: 297–300
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