Does this patient have dialysis-associated vascular steal syndrome?

Symptoms (the classic 6 Ps)

• Pain

• Paresthesia

• Paralysis

• Pulselessness

• Poikilothermia

• Pallor

• Symptoms worsen during dialysis particularly in the setting of intradialytic hypotension, and during cold weather

Signs

• Pallor

• Decreased sensation

• Diminished pulses

• Acrocyanosis

• Digital gangrene

Differential diagnosis

• Dialysis-associated muscle cramp

• Diabetic or uremic polyneuropathy

• Entrapment neuropathy including beta-2 microglobulin amyloidosis

• Reflex sympathetic dystrophy

• Acute ischemic monomelic mononeuropathy (ischemic nerve injury following the creation of an arteriovenous fistula or graft)

• Calciphylaxis

What tests to perform?

This is a clinical diagnosis based on the history and physical examination; noninvasive and invasive imaging studies may be used to support the diagnosis.

Imaging studies

Pulse oximetry (decreased waveform, pulse gradient compared with unaffected side, oxygen desaturation on affected side if severe)

Plethysmography

Digital-brachial index (DBI), which is the ratio of the brachial to digital blood pressure (measured on the fingers)

No absolute value for the index to predict the development of steal; DBI < 1.0 suggests increased risk

DBI < 0.6 provides a sensitivity of 100% and a specificity of 76%

DBI < 0.8 provides a sensitivity of 29% and a specificity of 93%

Doppler flow (diminished pressure and waveform on the affected side with the corresponding wrist/brachial index)

Angiography

How should patients with dialysis-associated vascular steal syndrome be managed?

Depends on severity and vascular access anatomy

Mild (cool extremity with few symptoms but steal demonstrable by flow augmentation with access occlusion): Supportive and symptomatic care: use of gloves and hand exercise

Moderate (intermittent ischemia only during dialysis/claudication): vascular intervention required if supportive care fails or symptoms worsen

• Percutaneous luminal angioplasty (inflow or outflow arterial disease)

• Surgical intervention with preservation of vascular access:

Correction of arterial inflow stenosis/occlusion

Flow limiting procedures (e.g., banding, outflow reduction, or anastomosis reduction)

Proximalization of arterial anastomosis

Revision using distal inflow

Ligation of artery distal to anastomosis

Distal revascularization and interval ligation (DRIL)

Distal revascularization without interval ligation

Severe (ischemic pain at rest/tissue loss)

Surgical ligation of vascular access with loss of access

What happens to patients with dialysis-associated vascular steal syndrome?

Limb ischemia

Limb gangrene

Vascular access dysfunction

How to utilize team care?

1. Specialty consultations: vascular medicine and vascular surgery

2. Nurse: Promote hand exercise

3. Pharmacist: Review and check drugs that may worsen vasoconstriction such as beta-blockers

Are there clinical practice guidelines to inform decision making?

Applications

2006 Clinical Practice Guidelines for Vascular Access (Published by National Kidney Foundation, K/DOQI)

Other considerations

ICD-10-CM diagnosis code T82.818A: Embolism of vascular prosthetic devices, implants and grafts, initial encounter

ICD-10-CM diagnosis code T82.828A: Fibrosis of vascular prosthetic devices, implants and grafts, initial encounter

ICD-10-CM diagnosis code T82.838A: Hemorrhage of vascular prosthetic devices, implants and grafts, initial encounter

ICD-10-CM diagnosis code T82.848A: Pain from vascular prosthetic devices, implants and grafts, initial encounter

ICD-10-CM diagnosis code T82.858A: Stenosis of vascular prosthetic devices, implants and grafts, initial encounter

ICD-10-CM diagnosis code T82.868A: Thrombosis of vascular prosthetic devices, implants and grafts, initial encounter

ICD-10-CM diagnosis code T82.898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter