RESUMEN
A chronic hemodialysis patient was referred to interventional nephrology for evaluation of arteriovenous access dysfunction. The patient had been receiving hemodialysis using a left forearm brachiobasilic loop graft for the past 3 years. Physical examination revealed a hyperpulsatile graft. Angiography documented a critical stenosis at the vein-graft anastomosis and a well-developed basilic vein from the elbow to the axillary region. Central veins were patent all the way to the right atrium. All attempts to navigate the wire across the stenosis failed. The patient was educated and counseled regarding the possibility of surgical creation of a secondary arteriovenous fistula (AVF). The images obtained were shared and discussed with the surgeon. A plan to create a secondary AVF using the basilic vein in the arm was made. A few months later the patient was referred to interventional nephrology, this time for thrombectomy of the same left arm loop graft. Thrombectomy could not be performed and a right internal jugular tunneled catheter was inserted. The patient again was referred to the surgeon for AVF creation. Six weeks later the patient was seen in the interventional laboratory for removal of the right internal jugular tunneled catheter. It was noted that instead of a fistula, the patient had received a right forearm brachiocephalic loop graft. Devastating consequences, such as the lost opportunity to create a fistula, insertion of a tunneled dialysis catheter, arteriovenous graft placement, exhaustion of available sites for fistula creation, and exposure to increased morbidity and mortality associated with grafts and catheters, can result if the opportunity to create a secondary AVF is not availed in a timely manner. This concept must be understood by every member of the vascular access team.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/métodos , Fallo Renal Crónico/terapia , Diálisis Renal , Anciano , Angioplastia de Balón , Oclusión de Injerto Vascular/terapia , Humanos , Masculino , Reoperación , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Access ligation has been considered to be the treatment for patients presenting with arterial steal syndrome by many nephrologists. We report results of a prospective study using comprehensive arteriography coupled with percutaneous transluminal balloon angioplasty (PTA) or surgical intervention to evaluate and manage steal syndrome. METHODS: Twelve consecutive patients referred for symptoms of steal syndrome were examined. Comprehensive arteriography of the extremity to diagnose arterial stenoses and delineate anatomy was performed by advancing a diagnostic catheter into the subclavian artery. Findings of arteriography and degrees of stenosis before and after PTA also were documented. Resolution of symptoms after PTA and surgical interventions, as well as complications, were recorded. RESULTS: Angiography showed arterial stenotic lesions in 10 of 12 patients (83%). The degree of stenosis was 66% +/- 14% (SD). Eight patients (80%) with stenotic lesions underwent PTA successfully. The degree of stenosis after PTA was 13% +/- 10%. The remaining 2 patients were not considered candidates for PTA and were referred to surgery with arteriography images. One patient underwent ligation and the other patient required an axillary loop fistula using the same outflow vein. The 2 patients without stenoses showed excessive steal through the anastomosis and underwent lengthening procedures by insertion of a vein segment. All 12 patients are symptom free with a mean follow-up of 8.3 +/- 4 months, and 11 of 12 patients (92%) are dialyzing using the same access. There were no procedure-related complications. CONCLUSION: We suggest that complete imaging of the arterial circulation of the extremity be considered in patients presenting with symptoms of steal syndrome to properly assess the arterial anatomy and develop a treatment strategy.