Hemodialysis-related steal syndrome: predictive factors and response to treatment with the distal revascularization-interval ligation procedure.

Hand ischemia due to steal causes major disability in affected members of the hemodialysis population. Between February 2000 and March 2007, 24 patients aged 37-77 years were identified who developed hand ischemia distal to a hemodialysis access and required a distal revascularization-interval ligation (DRIL) procedure. Of the 24 patients, 22 (92%) were diabetic, 14 (58%) were women, 7 (29%) had prosthetic grafts, and 17 (71%) had fistulas, all originating from the brachial artery. Duration between the initial dialysis access and the DRIL procedures ranged 12 hours to 10 months. Conduits used were saphenous vein in 13 (54%) cases, cephalic vein in 3 (12%) cases, basilic vein in 5 (21%) cases, and prosthetic grafts in 3 (12%) cases. There were no operative deaths. Improved blood flow and relief of symptoms were observed in 23 (96%) patients. The procedure failed early in one patient who had thrombosis of a prosthetic graft. Two patients required digital amputations. At a median follow-up of 50 months, 14 (58%) patients died using the access requiring the DRIL, 2 (8%) did not require dialysis, 3 (12%) were using a new access, and 5 (21%) were still using the access that had required the DRIL. In late follow-up, only one DRIL bypass required revision and the remainder were patent. One patient developed an ischemic hand 5 years after his DRIL procedure despite a patent bypass. The development of ischemic steal requiring performance of a DRIL procedure is most likely to occur in diabetic patients with dialysis access originating from the brachial artery. The procedure is effective in ameliorating symptoms while preserving the vascular access. The high long-term mortality rate observed in this series underscores the fact that patients requiring a DRIL procedure represent a subset of dialysis patients with advanced diabetic vascular disease and a limited life expectancy. Despite the effectiveness of the DRIL procedure, efforts should be concentrated on prevention of ischemic steal in order to lessen the morbidity and expense of this condition in the dialysis population.

Nonoperative management of acute spontaneous renal artery dissection.

Isolated spontaneous renal artery dissection is a rare condition that can result in renal parenchymal loss and severe hypertension. Although several risk factors have been identified in association with renal artery dissection, the natural history is not well defined. The rarity and nonspecific presentation of the disease often lead to diagnostic delay. That, coupled with the anatomic limitations imposed by dissection into small branch arteries, frequently precludes successful revascularization. Over a 12-month period, four cases of spontaneous renal artery dissection (SRAD) were treated at a single institution. The patients (ages 44-58 years) presented with acute onset of abdominal/flank pain, fever, and hematuria. Diagnostic work-up included an abdominal CT scan revealing segmental renal infarction. Angiographic evaluation was diagnostic for renal artery dissection in all cases. In one case there was evidence of fibromuscular dysplasia (FMD), and in a second there was acute dissection superimposed upon atherosclerotic disease. Diagnosis was made within 12-72 hr of the onset of symptoms. All patients were managed expectantly with anticoagulation. Two patients were known to have a history of hypertension prior to admission. All four patients have required antihypertensive treatment following dissection, but the condition has been easily controlled. Renal function has remained stable in all cases. None of the four cases required exploration. Two of the four patients underwent repeat angiographic evaluation for recurrent symptoms of pain. In the case of the patient with FMD, a new dissection was seen in the contralateral renal artery, and in the second, repeat angiogram revealed proximal remodeling of the dissected artery. Management strategies for SRAD include surgical revascularization, endovascular intervention, and observation with or without anticoagulation. The available literature does not demonstrate a clear benefit of treatment with any of these modalities. In the short term, the combination of anticoagulation and expectant management appears to produce satisfactory outcomes for this difficult problem.