Upper extremity arterial endovascular interventions for symptomatic vascular access-induced steal syndrome

• Published in: Journal of vascular surgery 2019-12, Vol.70 (6), p.1896-1903.e1
• Main Authors: Cheun, Tracy J., Jayakumar, Lalithapriya, Sideman, Matthew J., Pounds, Lori L., Davies, Mark G.
• Format: Article
• Language: English
• Subjects: Bypass; Critical ischemia; Endovascular; Outcomes; Upper extremity
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2019.01.072

Critical hand ischemia owing to vascular access-induced steal syndrome (VASS) continues to be a significant problem. The aim of this study was to examine the outcomes of arterial endovascular interventions in the upper extremity of patients presenting with VASS. A database of patients presenting with documented VASS between 2006 and 2016 was retrospectively queried. Patients who underwent isolated endovascular intervention in the upper extremity were analyzed. Ninety-eight patients (66% female; average age 65 years) presented with VASS: 28 presented with upper arm atherosclerotic disease above the arteriovenous (AV) anastomosis (above elbow) and the remaining 70 patients with below AV anastomotic atherosclerotic disease at the elbow (below elbow). Sixty-three percent of the entire patient cohort (N = 65) presented with rest pain and the remainder (n = 33 [34%]) with minor digital ulceration. Of those with upper arm disease above the AV anastomosis, one-third of patients had subclavian occlusive disease and two-thirds had brachial artery occlusive disease. Patients with subclavian disease underwent stent placement, and patients with brachial artery disease underwent balloon angioplasty. Technical success was 100% (n = 28). Ninety-one percent of these patients (n = 25) had symptomatic success at 30 days and the remainder (n = 3) required proximalization of the access. Of those with below AV anastomosis at the elbow disease, all had disease in the forearm vessels with 42% (n = 29) having either the ulnar or radial artery occlusion. Balloon angioplasty was performed in one vessel in 55% (n = 38) and in two vessels in 45% (n = 32) of patients. Technical success was 79% (n = 81 of 102 vessels) with 51% of the patients (n = 36) having symptomatic success at 30 days; of those who remained symptomatic, 80% (n = 27) required proximalization of the access and 20% (n = 7) required ligation. The major adverse cardiovascular event rate for the entire patient cohort was 4% (n = 4). The 30-day complications for the entire patient cohort included continued steal (38%; all resolved with secondary procedures), thrombosis (3%; all forearm vessels treated for occlusion), bleeding (0%), infection (0%), and mortality (1%). Primary clinical success defined as the relief of distal ischemic symptoms and the preservation of a functional access site for dialysis showed rates of 42 ± 9% (mean ± standard error of the mean) and 0 ± 0% at 5 years (above and below elbow groups, respective