Management of hand ischemia in patients with hemodialysis access by distalarterial ligation and revascularization

Hand ischemia due to arterial steal syndrome is an infrequent but potential ly serious complication of hemodialysis access procedures. Correction of sy mptomatic steal syndrome typically involves fistula ligation, arterial band ing, or graft lengthening each of which provides varying degrees of success . The purpose of this study is to evaluate experience in the treatment of d ialysis-associated hand ischemia by distal artery ligation and revasculariz ation. A retrospective review was performed on 14 patients over a 6-year pe riod who developed hand ischemia following hemodialysis access construction and underwent distal artery ligation and revascularization. Patient demogr aphic data, operative indications, risk factors, and treatment outcome were noted. There were 10 men and four women, with a mean age of 52 years (rang e 21 to 73). Hand ischemia occurred in nine patients with arteriovenous gra fts and five patients with arteriovenous fistulas. Nine patients developed steal syndrome within 1 month following the hemodialysis access procedure. All 14 patients underwent a surgical procedure for hand ischemia, which inc luded ligation of the artery distal to arteriovenous fistula and arterial b ypass, with reverse saphenous vein grafts in 10 patients, reversed cephalic vein grafts in three patients, and polytetrafluoroethylene graft in one pa tient. One patient with severe digital gangrene also required amputation. T here was no perioperative morbidity or mortality. Following operation, all showed immediate improvement of the affected hand and remained free of symp toms. The cumulative patency rates of the hemodialysis access following the corrective procedure at 1, 3, and 5 years were 85.7%, 64.2%, and 42.9%, re spectively. All arterial bypasses remained patent during follow-up, which r anged from 1 month to 5 years (mean 35 months). Distal arterial ligation wi th revascularization is an effective and durable treatment for patients wit h arterial steal syndrome following hemodialysis access construction. This technique can be performed with minimal morbidity and maintains a continuou s access for hemodialysis.