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M Mazen Hachem *, MD, PhD, FACS., M Bosaeed * and M Wakka * * Division of Vascular Surgery

Upper Limb Ischemia After Vascular Access Surgery Differential Diagnosis and Management. M Mazen Hachem *, MD, PhD, FACS., M Bosaeed * and M Wakka * * Division of Vascular Surgery King Abdul-Aziz Medical City Jeddah, KSA. Ischemic Complications of VA. Duncan et al., JVS 4: 144, 1986

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M Mazen Hachem *, MD, PhD, FACS., M Bosaeed * and M Wakka * * Division of Vascular Surgery

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  1. Upper Limb Ischemia After Vascular Access Surgery Differential Diagnosis and Management • M MazenHachem*, MD, PhD, FACS.,M Bosaeed* and M Wakka* • *Division of Vascular Surgery • King Abdul-Aziz Medical City • Jeddah, KSA

  2. Ischemic Complications of VA Duncan et al., JVS 4: 144, 1986 Odland et al., Surgery 110:664, 1991 • Ischemic Steal Syndrome (ISS) & Ischemic Monomelic Neuropathy (IMN) are devastating complications of VA procedure and mostly are subject to malpractice & lawsuit • 90% have steal phenomena • 5-20% have ischemic steal syndrome • 0.5-1% have IMN

  3. Ischemic Complications of VAIschemic Steal Syndrome • ISS results from uncompensated steal phenomena Regardless of VA flow • Poor collaterals • Proximal arterial stenosis • Reversible if treated promptly

  4. Ischemic Complications of VAIschemic Monomelic Neuropathy • IMN results from blood flow alteration to vasanervosum of Median, Radial & Ulnarnerves producing claw hand.Regardless of VA flow. • Irreversible even with appropriate strategy and early intervention. • Absence of severe tissue ischemia differentiate IMN from ISS.

  5. Objectives • Recognize clinical presentations • Ischemic Steal Syndrome • Ischemic Monomelic Neuropathy • Be familiar with treatment options • Select appropriate treatment options for each case.

  6. Ischemic Steal SyndromeDiagnosis • History/ Physical examination • Coldness • Radial pulse W/O access occlusion • Motor weakness & Sensory deficit • Trophic changes (late SS).

  7. Ischemic Steal SyndromeDiagnosis • Vascular Lab • Significant reduction in digital pressure and pulse volume recording • Digital pressure and pulse volume improve • Occlusion of AVF • Occlusion of V outflow • Occlusion of RA distal to AVF • Digital pressure and pulse volume made worse • Occlusion of RA proximal to AVF • Occlusion of UA • Angiogram

  8. Grading of Ischemic Steal Syndrome

  9. Ischemic Steal Syndrome Goals of Treatment Restore perfusion to the hand Maintain Vascular Access

  10. Ischemic Steal Syndrome Treatment Options • Do nothing • PTA • Surgery • Access ligation • Banding • Distal Revascularization-Interval Ligation (DRIL) • Distalizaion of arterial inflow (RUDI) • Proximalization of arterial inflow (RUPI) • Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER)

  11. Treatment Options Restore perfusion Lost Vascular Access “Blind” banding w/o consideration of access flow is ineffective and ill-advised. Access Ligation Banding

  12. Treatment Options Bypass increase distal flow Eliminate steal phenomena due to arterial ligation Resolved ischemia Distal flow depending bypass What’s a DRIL Procedure? Procedure Schanzer H, Schwartz M, Harrington E, Haimov M: Treatment of ischemia due to “steal” by arteriovenous fistula with distal artery ligation and revascularization. J VascSurg 7: 770–773, 1988

  13. Brachial artery Cephalic vein Anastomosis site Brachial-to-brachial bypass Interval ligation mmhachem 2006-2007

  14. Treatment Options Increase distal flow Decrease steal phenomena Distal ischemia resolved Minion DJ, Moore E, Endean E: Revision using distal inflow: A novel approach to dialysis-associated steal syndrome. Ann Vasc Surg 19: 625–628, 2005 RUDI Procedure

  15. Treatment Options Increase distal flow Eliminate steal phenomena due to high graft resistant Resolved ischemia RUPI Procedure J Zanow, U Kruger, H Schlz: Proximalizationof arterial inflow: A new technique to treat access-related ischemia; J VascSurg, 43:1216-1221, 2006

  16. Treatment Option Minimally Invasive Limited Ligation Endoluminal assisted Revision Gregg A. Miller, MD. 2006 What’s a MILLER Outpatient Procedure

  17. MILLER Procedure

  18. Treatment Options Guideline Access FLOW MEASURMENT

  19. Treatment Options GuidelineMeasurement Access Blood Flow • Access blood flow will dictate management option: • Low or normal access flow • DRIL • High access flow • MILLER or RUDI or RUPI

  20. Results

  21. Conclusion • Pay special attention to the elderly diabetic females with neuropathy • Immediate evaluation if post-op hand pain or other evidence of significant ischemia • Diagnosis almost can be made on clinical features & non-invasive studies • Angiogram is mandatory • Proximal arterial stenosis is a common contributing factor to hand ischemia

  22. Conclusion • Surgical treatment should provide • Adequate access flow • Restoring adequate flow to the extremity. • Main treatment options for ischemic steal syndrome • MILLER procedure • RUDI • RUPI • DRIL • Challenge is there for IMN

  23. Thank You

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