Endovascular treatment of

ischemia associated with the

vascular access

Luc Turmel-Rodrigues

Tours, Neuilly-sur-Seine, France

Patient with a left radial-cephalic AVF,

referred for prolonged bleeding times

and probable stenosis of the outflow vein

The radiologist is often the first to make the diagnosis.

Shake the hand ipsilateral to the fistula: coldness, pain

The patient had

complained of

chronic hand pain

since placement

of this fistula

5 months before

Dialysis teams

frequently

overlook

hand ischemia

Hand ischemia: a delayed or overlooked

diagnosis…

• Constant pain somewhere

• Nurses look at the fistula, not at the hand

• Many elderly patients, not demanding, poorly

concerned by hand impairment since…

they do nothing!

Any pain or cutaneous problem

ipsilateral to a fistula is the

CONSEQUENCE of the STEAL of

the FISTULA on the arterial supply,

until you can prove that it is not

Hand ischemia

RULE # 1

Search as a priority for stenosis of a feeding artery

amenable to percutaneous treatment

Hand ischemia RULE # 2

ISCHEMIA

We probably have to discourage glycemic samples

ipsilateral to a fistula as it might trigger hand ischemia

An ethical problem +++

*NOBODY has ever published an extensive experience

*NOBODY can claim « I KNOW this topic and I never experienced ANY wrong reasoning or failure »

• DIFFICULT problem , multidisciplinary approach and discussion is mandatory to limit failures

At such late stages, urgent fistula ligation is

most often the only solution, especially for

teams not familiar with the management of ischemia

Pathophysiology (1)

Hand ischaemia is rare in non-dialysed patients and is due either to trauma, embolism or intrinsic disease

In patients with arteriovenous access, hand ischemia occurs:

• in up to 28% of elbow accesses (fed by the brachial artery)

Eur J Vasc Endovasc Surg 2008;35:619-624

*…but is as low as 2% only in forearm fistulas

(fed by the radial or the ulnar artery)

Pathophysiology (2)

• After fistula creation, a significant proportion of blood running in direction of the hand is diverted into the fistula

• However, a normal brachial artery will enlarge and the overall blood supply to the limb will increase dramatically after creation of an arteriovenous fistula (from 150 ml/min to an average of 1 litre/min…with cases above 3 L / min)

• Hand ischemia appears when the steal exerted by the fistula does not leave sufficient residual blood flow the hand

Pathophysiology (3)

• Onset if ischemia is UNPREDICTABLE

but risk increased in all patients with peripheral arterial disease: diabetics, smokers, elderly…

• However, even a low flow fistula can disrupt a precarious arterial supply to the hand

Hand ischemia occurs in

up to 28% of elbow accesses

(fed by the brachial artery)

…but in only 2%

of forearm fistulas (fed by the

radial or the ulnar artery)

Surgeons, do create FOREARM fistulas FIRST !

Absolute contraindication to any dilatation of the

arterialised vein (would increase fistula flow and steal)

Steal syndrome !

Steal syndrome ?

How to assess the diagnosis ???

How to be sure that this is due to hypoperfusion ??

Duplex ultrasound first whenever

possible

• Looks for arterial stenoses/occlusions

• Measures fistula flow rate

• Indicates direction of flow in arteries distal to the

anastomosis

• Digital pressure measurement by

photoplethysmography

• Digito-brachial index

Duplex ultrasound

« steal syndrome » is confirmed when:

- Digital arterial pressure measurement by

photoplethysmography < 50 mm Hg

- Digito-brachial index < 0.6

(finger systolic pressure divided by

systolic pressure in the brachial artery)

-HIGH SENSITIVITY +++, low specificity +

TREATMENT of AVF-ASSOCIATED HAND ISCHEMIA

1 -improve arterial supply to the hand

And / Or

2- decrease fistula flow and subsequent steal

IMAGING BEFORE TREATMENT

1 -improve arterial supply to the hand

IMAGE ALL ARTERIES FROM THE OSTIUM

OF THE SUBCLAVIAN ARTERY TO FINGERS

(dilatation/ bypass)

And/Or

2- decrease fistula flow and subsequent steal

LOOK FOR THE DIRECTION OF FLOW IN ARTERIES

distal to the anastomosis

(modifications of the inflow, ligations)

ENDOVASCULAR TREATMENT

of AVF-ASSOCIATED HAND ISCHEMIA

1 -improve arterial supply to the hand

=DILATION + stent of stenoses in

arteries feeding the hand

And / Or

2- decrease fistula flow and subsequent steal

=EMBOLISATION

of an artery stealing the hand

How to perform a good angiography

• Imaging technique: DSA, CTA and MRA

• Approach: arterialized vein, brachial or femoral a.

• Contrast medium: Visipaque® best (no pain)

• Runs: from aortic arch to finger pads

• Interpretation: search for stenosis/occlusion,

collaterals, direction of flow, residual AVFs

• Central venous outflow

Baer et al.

Kidney Int 2008, 73:1203-4

…the fistula was ligated surgically…

CT angiography:

the beauty of the Devil…

Dangerous to the venous reserve

does not allow concomitant PTA

Yerram, P. et al. Clin J Am Soc Nephrol 2007;2:258-263

Shiny, discolored, woody skin (on inspection and palpation) seen in the patient with

Nephrogenic Systemic Fibrosis (NSF)

The dangers of gadolinium… © Godier

MRA

ABSOLUTE PRIORITY:

Rule out a stenosis of the

feeding artery amenable

to dilatation/stent

Upper arm AVFs:

look at subclavian,

axillary and brachial

Forearm AVFs:

look also at the

ulnar artery

and to the

direction of flow

in the distal

radial artery

When all the proximal brachial

artery flow runs into the

fistula, the distal brachial artery

and forearm arteries rely on

collaterals originating

from the axillary artery

STENOSIS ???

Pseudo stenosis (« no flow » area)

« normalized » aspect under

manual compression

of the arterialized vein

Running fistula Under fistula compression

Cured by a DRIL

Distal

Revascularisation

Interval

Ligation

bypass improving

distal arterial flow

+

ligation suppressing

retrograde steal

ABSOLUTE PRIORITY:

Rule out a stenosis amenable to dilatation/stent in

an artery feeding the hand

Not a 0% risk procedure

Not a 100% clinical success rate

2 stenoses at subclavian and axillary levels

Ischemia cured after double arterial dilation

(small) risk of cholesterol emboli…

Axillary artery stenosis

High origin of a forearm artery in 15 to 20% of patients

Stenosis of the

ulnar artery

Dilation of SHORT ulnar artery

stenoses works

because this is a relatively

high flow artery feeding the

hand AND the fistula

52-year male

Type 1 diabetes

3 m

Angioplasty of below the

elbow arteries in critical

hand ischemia Ferraresi R, Eur J Vasc Endovsc Surg 2012

Balloon inflation

(Anphirion Deep, Medtronic Invatec):

diameter 2.5-3.0, conic, 21 cm long, 15 atm

Conclusion:

look at the ulnar artery

…….and dilate… 2nd finger necrosis

Complete healing

at 3 months

ENDOVASCULAR TREATMENT

of AVF-ASSOCIATED HAND ISCHEMIA

1 -improve arterial supply to the hand

=DILATION + stent

And / Or

2- decrease fistula flow and subsequent steal

=EMBOLISATION

Flow reduction by banding

Conflicting results in the literature:

too loose ineffective or too tight causing thrombosis

…a real lottery ! As usual, 1 article reports fabulous results….

surgery

MILLER

-Retrograde flow IS THE RULE in distal radial arteries,

but very few fistulas (2%) actually STEAL the hand,

-risk increased with time (ageing of arteries, flow)

Post dilat 3 mm

Post embolization

with a coil

Coil

DOUBLE

TREATMENT

Post dilat 3 mm

Post embolization

with a coil

DOUBLE

TREATMENT

Dilation of the ulnar artery OR embolisation/ligation

of the distal radial artery: what is the best?

-It is more satisfying to reopen than to close an artery

-embolisation/ligation of the distal radial artery

may not be clinically efficient, symptoms of

hand ischemia can worsen…

Diseased

ulnar artery

Major stenosis of the anastomosis

Perfect vein +++

LIGATE !

Some rare cases

• Residual additional fistula

• Distal emboli from a residual stump

« brachial-basilic » (in fact « radial-basilic ») fistula

surgically revised developing hand ischemia

*high bifurcation of the radial artery

*stump of the previous anastomosis

*reversal of distal radial artery flow

Residual flow in a more distal

fistula which never matured:

should be ligated or

embolized

Formation of clots in the residual stump of an elbow

fistula with migration into the distal radial artery

Distal

Revascularisation

Interval

Ligation

bypass improving

distal arterial flow

+

ligation suppressing

retrograde steal

Stenosis of the venous bypass

Revision

Using

Distal

Inflow

Brachial inflow replaced by radial artery inflow

by interposition of a prosthetic graft but…+/- rapid

development of stenosis at the venous anastomosis

RUDI

July 2000

Transposition of

the radial artery

(native RUDI technique)

Revision

Using

Distal

Inflow

November 2006

720 ml / min

310 ml /min

760 ml / min

Pre dilatation

Post dilat

Ischaemia of venous origin

Due to venous outflow stenosis causing

chronic venous reflux to the hand

Increasing, overlooked, underestimated problem

Late diagnosis, difficult treatment, poor surveillance

1

Any pain or cutaneous trouble

ipsilateral to a fistula is the

CONSEQUENCE of the STEAL of

the FISTULA on the arterial supply

until you can prove that it is not

2

in up to 28% of elbow accesses

(fed by the brachial artery)

*…but is as low as 2% only

in forearm fistulas (fed by the

radial or the ulnar artery)

Surgeons, do create FOREARM fistulas FIRST !

3

ABSOLUTE PRIORITY:

Rule out a stenosis

amenable to dilatation/stent

in an artery feeding the hand

4

Absolute contraindication to any dilatation of the

basilic vein (would increase fistula flow and steal)

5