M Mazen Hachem*, MD, PhD, FACS., M Bosaeed* and M Wakka* *Division of Vascular SurgeryKing Abdul-Aziz Medical City

Jeddah, KSA

Upper Limb Ischemia After Vascular Access Surgery

Differential Diagnosis and Management

Ischemic Complications of VA• Ischemic Steal Syndrome (ISS) & Ischemic

Monomelic Neuropathy (IMN) are devastating complications of VA procedure and mostly are subject to malpractice & lawsuit

• 90% have steal phenomena– 5-20% have ischemic steal syndrome– 0.5-1% have IMN

Duncan et al., JVS 4: 144, 1986Odland et al., Surgery 110:664, 1991

Ischemic Complications of VAIschemic Steal Syndrome

• ISS results from uncompensated steal phenomena Regardless of VA flow–Poor collaterals–Proximal arterial stenosis•Reversible if treated promptly

Ischemic Complications of VAIschemic Monomelic Neuropathy

• IMN results from blood flow alteration to vasa nervosum of Median, Radial & Ulnar nerves producing claw hand. Regardless of VA flow.– Irreversible even with

appropriate strategy and early intervention.

• Absence of severe tissue ischemia differentiate IMN from ISS.

Objectives1. Recognize clinical presentations – Ischemic Steal Syndrome– Ischemic Monomelic Neuropathy

2. Be familiar with treatment options3. Select appropriate treatment options for

each case.

Ischemic Steal Syndrome Ischemic Monomelic Neuropathy

Predominant feature Cold hand with pain onor off dialysis

Weakness and paralysisof muscles withprominent sensory loss

Onset Acute and chronic Immediately

Access type Common with upperarm but also seen withforearm accesses

Only in proximal access

Sex Variable Female>Male

Tissue involved Skin > muscle > nerve NervesCause Vascular insufficiency

leading to distalhypoperfusion

Vascular insufficiencycausing nerve damage

Radial pulse Usually diminished or absent Usually presentDiagnostic evaluation History,/ physical examination,

and arteriographyHistory and the clinicalfeatures

More prevalent in Patients with diabetes,peripheral vasculardisease, smokers

Patients with diabetes,peripheral vascularDisease + PN

Management strategies Percutaneous and orSurgery

Access ligation?????

Ischemic Steal Syndrome Diagnosis

• History/ Physical examination– Coldness– Radial pulse W/O access

occlusion– Motor weakness &

Sensory deficit– Trophic changes (late

SS).

Ischemic Steal Syndrome Diagnosis

• Vascular Lab– Significant reduction in digital pressure and pulse volume

recording– Digital pressure and pulse volume improve• Occlusion of AVF• Occlusion of V outflow• Occlusion of RA distal to AVF

– Digital pressure and pulse volume made worse• Occlusion of RA proximal to AVF• Occlusion of UA

• Angiogram

Grading of Ischemic Steal SyndromeGrade Symptoms Management

0 Asymptomatic Nothing

I Cold hand with tolerable symptomsFlow augmentation by access occlusion

Observation

II Ischemic symptoms during dialysis“Claudication”

Non-Invasive StudyMedical + Angiogram PTA/ Surgery

III Rest pain / Tissue loss Angiogram & proceed

Ischemic Steal Syndrome Goals of Treatment

• Restore perfusion to the hand• Maintain Vascular Access

Ischemic Steal Syndrome Treatment Options

• Do nothing• PTA• Surgery

1. Access ligation2. Banding3. Distal Revascularization-Interval Ligation (DRIL)4. Distalizaion of arterial inflow (RUDI)5. Proximalization of arterial inflow (RUPI)6. Minimally Invasive Limited Ligation Endoluminal-

Assisted Revision (MILLER)

Treatment Options

• Restore perfusion• Lost Vascular Access

• “Blind” banding w/o consideration of access flow is ineffective and ill-advised.

Access Ligation Banding

Treatment Options

• Bypass increase distal flow

• Eliminate steal phenomena due to arterial ligation

• Resolved ischemia– Distal flow depending bypass

What’s a DRIL Procedure? Procedure

Schanzer H, Schwartz M, Harrington E, Haimov M: Treatment of ischemia due to “steal” by arteriovenous fistulawith distal artery ligation and revascularization. J Vasc Surg 7: 770–773, 1988

mmhachem 2006-2007

Brachial artery

Brachial-to-brachial bypass

Cephalic vein

Anastomosis site

Interval ligation

Treatment Options

• Increase distal flow• Decrease steal

phenomena • Distal ischemia resolved

Minion DJ, Moore E, Endean E: Revision using distal inflow:A novel approach to dialysis-associated steal syndrome.Ann Vasc Surg 19: 625–628, 2005

RUDI Procedure

Treatment Options

• Increase distal flow• Eliminate steal

phenomena due to high graft resistant

• Resolved ischemia

RUPI Procedure

J Zanow, U Kruger, H Schlz: Proximalization of arterial inflow: A new technique to treat access-related ischemia;J Vasc Surg, 43:1216-1221, 2006

Treatment Option

Minimally InvasiveLimitedLigationEndoluminal assistedRevision

Gregg A. Miller, MD. 2006

What’s a MILLER Outpatient Procedure

MILLER Procedure

ACCESS FLOW MEASURMENTTreatment Options Guideline

Treatment Options GuidelineMeasurement Access Blood Flow

• Access blood flow will dictate management option:– Low or normal access

flow• DRIL

– High access flow• MILLER or RUDI or

RUPI

RESULTS

Authors Year Proc. No. Pt. Results

De Caprio 1997 Banding 18 100% ischemia resolved1/11 AVG patent at 6 m0/7 AVF patent at 30 D

Haimovici 1996 DRIL 34 100% ischemia resolved73% AVG patency at 1 year96% bypass patency at 1 year

Hachem 2006 DRIL 16 90% ischemia resolved87.5% VA patency at1 year81% bypass patency at 1year

Zanow 2006 RUPI 30 80% ischemia resolved90% patency

MILLER 2010 MILLER 114 96% ischemia resolved90% patency at 1 year

Minion 2005 RUDI 6 100% ischemia resolved100% patency 14m

Minion 2005 RUPI 4 100% ischemia resolved100% patency at 1 year

Conclusion• Pay special attention to the elderly diabetic

females with neuropathy– Immediate evaluation if post-op hand pain or

other evidence of significant ischemia• Diagnosis almost can be made on clinical

features & non-invasive studies• Angiogram is mandatory

• Proximal arterial stenosis is a common contributing factor to hand ischemia

Conclusion• Surgical treatment should provide – Adequate access flow– Restoring adequate flow to the extremity.

• Main treatment options for ischemic steal syndrome– MILLER procedure– RUDI– RUPI– DRIL

• Challenge is there for IMN

Thank You