PATHOGENESIS AND MANAGEMENT OF UPPER-EXTREMITY ISCHEMIA FOLLOWING ANGIOACCESS SURGERY

Thirty-four patients with end-stage renal disease requiring hemodialys is developed over the course of 7 years (1987-1994) severe ischemia in the extremity carrying the angioaccess secondary to arterial 'steal'. Seven of these patients were treated with access ligation, 4 with ban ding reducing the flow through the access, and 23 with ligation of the artery distal to the inflow of the arteriovenous fistula and establis hing of an arterial bypass from a point 5 cm proximal to the fistula t o the distal artery. Of the 7 patients who underwent ligation, 5 had c omplete resolution of symptoms, 1 had persistent pain, and 1 patient h ad residual ischemic neuropathy. Of the 4 patients who underwent bandi ng, 3 lost their access due to thrombosis shortly after the banding pr ocedure, and in 1 patient partial resolution of symptoms was achieved. Of the 23 patients who underwent arterial ligation-bypass procedure, all showed immediate signs of improvement. One patient who presented w ith advanced gangrene eventually required amputation, and 3 patients h ad some residual symptoms. The cumulative patency of the access with t his procedure was 73% at 1 year and 45.5% at 2 years. The patency for the bypass was 95.6% at 1 and 2 years. The arterial ligation-bypass pr ocedure is currently the treatment of choice for patients developing s evere ischemia secondary to 'steal' following construction of an arter iovenous fistula for dialysis.