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Vascular Medicine
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case-report

Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis

Payman Zamani

Cardiovascular Division, Veterans Affairs Boston Healthcare System and Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School

James Kaufman

Renal Division, Veterans Affairs Boston Healthcare System and Boston University School of Medicine

Scott Kinlay

Cardiovascular Division, Veterans Affairs Boston Healthcare System and Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical Schoolscott.kinlay{at}va.gov

Abstract

Arteriovenous fistulae in the arm are commonly used for hemodialysis in end-stage renal disease. Although physiological steal with reverse flow in the artery distal to the fistula is common, hand ischemia or infarction are rare. The ischemic steal syndrome (hand or forearm ischemia) is usually a result of arterial disease proximal or distal to the fistula and/or poor collateral supply to the hand. The diagnosis is primarily clinical; however, markedly reduced digital pressures and pulse volume recordings support the diagnosis. Management requires imaging for focal stenoses or disease in arteries proximal and distal to the fistula from the aorta to the hand. We present a case caused by subclavian artery occlusion that was initially missed due to focusing investigation only on the fistula. We describe the percutaneous treatments and surgical revisions that attempt to restore flow to the hand without compromising the fistula.

Key Words: angioplasty • fistula • gangrene • ischemia • peripheral vascular diseases • subclavian artery • vascular fistula

Vascular Medicine, Vol. 14, No. 4, 371-376 (2009)
DOI: 10.1177/1358863X09102293
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