RESUMEN
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.
Asunto(s)
Angioplastia de Balón , Diálisis Renal/efectos adversos , Enfermedades Vasculares/terapia , Adulto , Anciano , Algoritmos , Angiografía , Derivación Arteriovenosa Quirúrgica , Arteria Braquial/patología , Constricción Patológica , Femenino , Humanos , Riñón/irrigación sanguínea , Masculino , Persona de Mediana Edad , Arteria Radial , Síndrome , Resultado del Tratamiento , Enfermedades Vasculares/etiologíaRESUMEN
BACKGROUND: Traditionally, arteriovenous hemodialysis access inflow stenosis has been reported to occur infrequently (0% to 4%). In contrast, recent reports have suggested a significantly higher incidence (14% to 42%). Interpretation of these studies has been complicated by the presence of one or more confounding factors such as retrospective study design, small sample size, arteriovenous fistulas grouped with grafts to determine the incidence of inflow stenosis, inclusion of fistulas that had failed primarily, failure to provide adequate definition of inflow stenosis, and the technique of retrograde angiography. This is a report of a prospective, multicenter study to examine the incidence of inflow stenosis separately in arteriovenous fistulas and grafts. METHODS: Patients were referred to interventional nephrology either for percutaneous balloon angioplasty or thrombectomy procedures. Angiography to evaluate access inflow (arterial anastomosis and adjacent vascular structures) was performed in all cases. This was accomplished by retrograde angiography using either manual occlusion of the venous side and/or advancing a diagnostic catheter across the arterial anastomosis. Multiple images using digital subtraction angiography were recorded in multiple planes. An inflow stenosis was 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). Vascular stenosis was defined as >/=50% reduction in luminal diameter judged by comparison with either the adjacent vessel or graft. A standardized definition for anastomotic stenosis was applied. RESULTS: Two hundred and twenty three consecutive procedures (grafts, 122; fistulas, 101) were performed in 158 patients. Inflow stenosis occurred in 36/122 (29%) in graft cases. All had a coexisting stenosis on the venous side. In fistula cases, 41/101 (40%) had inflow stenosis. Of these, 22 (54%) had a coexisting lesion on the venous side. Overall, inflow stenosis occurred in 77/223 procedures (35%). CONCLUSION: This prospective, multicenter study demonstrates that access inflow stenosis occurs in one third of the cases referred to interventional facilities with clinical evidence of venous stenosis or thrombosis. This is much higher than has been traditionally reported.