Combating Steal: Percutaneous Interventions for Dialysis Access Steal Syndrome

Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution’s 20-Year Experience

Clinical question

To evaluate the outcomes of percutaneous interventions in Dialysis Access Steal Syndrome and assess their safety and effectiveness .

Take away point

Percutaneous interventions in patients with Dialysis Access Steal Syndrome was demonstrated to provide symptomatic improvement, and decrease the need for follow up surgical intervention.

Reference

Rigsby DC, Clark TWI, Vance AZ, Chittams J, Cohen R, Mantell MP, Kobrin S, Trerotola SO. Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution's 20-Year Experience. J Vasc Interv Radiol. 2024 Apr;35(4):601-610. doi: 10.1016/j.jvir.2023.12.566. Epub 2024 Jan 1. PMID: 38171415.

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Study design

Retrospective single institutional study

Funding Source

None reported

Setting

Academic: Perelman School of Medicine, University of Pennsylvania

Figure

Figure 1. Flow diagram describing patient progression from initial dialysis access steal syndrome (DASS) evaluation by a referring surgeon to interventional radiology (IR) percutaneous study with or without intervention to follow-up. DRAE = distal radial artery embolization.

Summary

 
Dialysis access steal syndrome (DASS) occurs when blood flows preferentially through the dialysis access circuit, depriving downstream tissues of oxygen-rich blood. This can lead to pain, ulcers, and tissue loss in the ipsilateral limb in up to 10% of dialysis patients. Known risk factors for DASS include older age, female sex, diabetes mellitus, coronary artery disease and peripheral arterial disease. Fistulography is recommended for initial diagnostic workup of DASS and can define the vascular anatomy and assess the degree of intervention required. Percutaneous interventions like distal radial artery embolization and minimally invasive ligation endoluminal-assisted revision percutaneous banding procedure can be performed and are described as the percutaneous equivalents to open surgeries, which include surgical access banding, distal revascularization with interval ligation, and distal radial artery ligation. Access ligation, which is the definitive treatment, is used sparingly due to the importance of maintaining hemodialysis access. Data on the clinical performance of percutaneous interventions is limited.

This study used data from a single institution over a period of 20 years. A retrospective chart review was performed for the 212 patients with 286 fistulograms meeting the inclusion criteria. Patient symptoms were recorded, flow through the access was quantified using a flow measurement (ReoCath, Transonic) catheter and categorized via the 2019 Kidney Disease Outcomes Quality Initiative. Each case fell into one of two categories: diagnostic fistulogram alone or undergoing fistulogram plus intervention. Technical success of the procedure was measured by reporting standards published by the Society of Interventional Radiology and clinical success by any reported improvement in DASS symptoms at the next follow up visit. Patients with severe ischemic tissue loss who received prompt surgical intervention were excluded.

The authors used a multiple logistic regression model to analyze the data, investigating the associations between DASS intervention and major adverse events, access preservation, and follow up surgery. Access was considered not preserved if follow up visit notes contained any indication of access abandonment or takedown. Covariates that were used in the regression model were female sex, upper arm access location, graft access type, diabetes mellitus, coronary artery disease and peripheral arterial disease. Odds ratios were also adjusted for correlation among multiple within-patient events using the robust Huber-White procedure.

Fistulograms revealed that 45% of patients had percutaneously treatable causes of DASS. Previous studies have reported anywhere from 20%-83% of patients having treatable causes of steal, but only about 33% of those patients underwent fistulograms before surgery. Two patients experienced adverse events that included a left common femoral artery hematoma and chest pain that required a 2-day hospital admission. The DASS interventions in this study demonstrated high rates of technical (94.0%) and clinical (54.2%) success that were consistent with similar modalities performed by vascular surgery. Analysis identified that the intervention group had 60% lower odds of follow up surgery and 70% lower odds of undergoing access revision surgery. Hemodialysis access preservation rate did not differ between the intervention and nonintervention groups, at an encouraging 88.0%.

There are limitations to this study that are due to its design, as a retrospective review it is unable to determine causality. The restriction to a single center also decreases the generalizability of the results to a broader population. There was a lack of complete follow up data due to an absence of standardized follow up intervals. This was mentioned by the authors that the true clinical success rate could be anywhere from 44% to 54% if all patients that were lost to follow up were accounted for.

Commentary

With an increasing prevalence of people receiving hemodialysis access, this study adds a large patient cohort to the Interventional Radiology literature on percutaneous management of DASS. Their analysis, which revealed that percutaneous interventions provided comparable outcomes to surgical interventions while maintaining a minimal side effect profile, was well designed and appropriately accounted for possible confounding variables. The implication was that Interventional Radiology can play a bigger role in the management algorithm of DASS and percutaneous interventions should be considered the first-line treatment for DASS. As the authors correctly noted, further research focusing on establishing causality through randomized control trials and investigating possible unintended consequences of percutaneous venous outflow optimization will elucidate the roles of percutaneous DASS interventions better.

Post Author

Anthony M. Camargo, BA
MD candidate, Class of 2025
University of Massachusetts Chan Medical School
@anthonymcamargo