|
|
| Journal of Vascular Access 2004; 5: 13 - 15 |
| Steal syndrome after brachiocephalic fistula for vascular access: Correction with a new simple surgical technique |
A.E. Henriksson 1, D. Bergqvist 2
1Department of Surgery, Sundsvall County Hospital - Sweden
2Department of Surgery, Uppsala University Hospital - Sweden
|
|
|
|
ABSTRACT
Purpose: Steal syndrome is the condition of arterial insufficiency distal to a permanent haemodialysis fistula. Three treatment options have been recommended: ligation of the fistula, banding of the fistula, and distal revascularization. We report an alternative simple surgical technique for correction of steal syndrome.
Methods: Two patients were treated for steal syndrome after brachiocephalic fistula operation. The treatment of the steal syndrome was done by interponating an ePTFE graft loop tunnelated subcutaneously in the upper arm.
Results: At follow-up one year later both fistula were patent without any reoperation and with normal flow at haemodialysis. There were no symptoms of steal.
Conclusion: This new method for correction of steal syndrome seems to be an attractive alternative. (The Journal of Vascular Access 2004; 5: 13-15)
Key Words. Dialysis access, Arterovenous fistula, Haemodialysis, Steal syndrome
Introduction
Steal syndrome is the condition of arterial insufficiency distal to a permanent haemodialysis fistula.
The arterial insufficiency is due to high flow through the fistula, reversal of flow in the artery distal to the anastomosis, and insufficient collateral circulation. The symptoms are pain, sensory loss, and loss of motor function. The diagnosis of steal is often made by compression of the fistula resulting in a return of the radial pulse and relief of symptoms. Three treatment options have been recommended (1).
The first is ligation of the fistula which, however, leads to loss of the angioaccess. Another method is plication or banding of the fistula to reduce flow through it (2). This method has a high risk of stenosis and thrombosis. The third option is distal revascularization with interval ligation technique (3). This technique is often successful in restoring function but the arterial bypass with two arterial anastomoses seems to give a considerable risk of arterial stenosis. We report an alternative simple surgical technique for the correction of steal syndrome.
Patients and methods
Two patients, a 69 year old diabetic man and a 76 year old nondiabetic woman, were treated for steal syndrome 1 and 3 months after brachiocephalic fistula operation. The symptoms were successively increasing pain, sensibility loss, and weakness of the hand. The radial artery pulse returned when the fistula was compressed. The flow through both fistulae was high, for the woman a value of 1.1 L per minute measured with duplex ultrasonography. The treatment of the steal syndrome was done by interponating a 40 cm respectively 30 cm ePTFE graft (Impra) (6 mm diameter) loop tunnelated subcutaneously in the upper arm (Fig. 1 a-d). The Kelly-Wick tunneling instrument was used to facilitate placement of the ePTFE graft.
Results
There was immediate postoperative relief of the symptoms and the radial pulse became palpable.
At follow-up one year later both fistulas were patent without any reoperation and with normal flow at haemodialysis. There were no symptoms of steal. One of the patients died after 15 months with a functioning fistula and the other one has a functioning fistula after 3 years postoperatively.
Discussion
In this report, a simple technique for correcting steal syndrome with preserved brachiocephalic fistula function is presented. The theoretical basis of the concept is the Poiseulles law which shows that the flow through a fistula depends on the length of the fistula. So if the fistula is prolonged the flow should be decreased. With the interposition of an ePTFE graft loop the flow is normalized through the fistula.
This method is simple in contrast to the by-pass technique and does not seem to give stenosis and thrombosis like plication or banding techniques. In a case report West et al used a PTFE graft conduit for interposition of a brachiocephalic side-to-side fistula (4). They opened the anastomosis of the fistula and interponated a PTFE-loop. In contrast we interponated the graft in the vein near the anastomosis.
Futhermore, they made the graft-loop cross the ventral part of the elbow, but we let the loop only run on the upper arm to avoid mechanical compression of the graft at the elbow. This new method for correction of a steal syndrome seems to be an attractive alternative but it has to be further tried before it is generally recommended.
Address for correspondence:
Anders Henriksson, MD, PhD
Department of Surgery
Sundsvall County Hospital
SE-851 86 Sundsvall - Sweden
anders.henriksson@lvn.se
REFERENCES
1. Murphy GJ, White SA, Nicholson ML. Vascular access for haemodialysis. Br J Surg 2000; 87: 1300-15.
2. Rivers SP, Scher LA, Veith FJ. Correction of steal syndrome secondary to hemodialysis access fistulas: a simplified quantitative technique. Surgery 1992; 112: 593-597.
3. Schanzer H, Skladany M, Haimov M. Treatment of angioaccess-induced ischemia by revascularization. J Vasc Surg 1992; 16: 861-6.
4. West JC, Evans RD, Kelly SE, et al. Arterial insufficiency in hemodialysis access procedures: reconstruction by interposition polytetrafluoroethylene graft conduit. Am J Surg 1987; 153: 300-1.
|
|
A.E. Henriksson
Printable Format (PDF)