Question

A 68-year-old male with chronic kidney disease underwent left brachiocephalic arteriovenous fistula 8 months back and is well functional. He complains of a feeling of coldness in left hand while undergoing dialysis for the past two months:
How will you manage him now and if this condition progresses?

Hint:

In severe cases of steal syndrome, early surgical or endovascular intervention is key to preventing irreversible tissue damage.

Answer 1

Step 1: Management of mild to moderate steal syndrome.
If the patient has mild or moderate symptoms (Grade 1 or 2), management involves conservative measures aimed at improving blood flow and reducing the symptoms. This includes:
1. Adjustment of dialysis flow rates: Reducing the flow rate of dialysis through the AV fistula may help in alleviating the symptoms of steal syndrome.
2. Compression: Use of compression garments or gloves can help improve distal circulation in the hand.
3. Medical therapy: Medications such as vasodilators (e.g., nitrates) may be used to improve blood flow to the distal hand.
4. Positioning: Elevating the arm may help relieve symptoms by improving venous return.

Step 2: Management of severe steal syndrome.
In cases of severe steal syndrome (Grade 3), where ischemia is severe and associated with tissue loss or resting pain, more invasive measures are necessary:
1. Surgical intervention: A fistula revision or arterial revascularization may be required to restore adequate blood flow to the hand. This may involve ligating the fistula or creating a new access site.
2. Endovascular treatment: If surgical intervention is not possible, endovascular techniques such as stenting or angioplasty of the feeding artery may be considered.
3. Fistula abandonment: In extreme cases, it may be necessary to abandon the existing fistula in favor of another access site, such as a catheter or graft.

Step 3: Long-term management and prevention.
- Monitoring: Regular follow-up with Doppler ultrasound to assess for recurrence or progression of steal syndrome.
- Dialysis access optimization: Ensuring that the dialysis access site is optimized to avoid further complications, including steal syndrome.

Step 4: Conclusion.
Management depends on the severity of steal syndrome, ranging from conservative measures in mild cases to surgical or endovascular interventions in severe cases. Early intervention is critical to prevent progression and tissue damage.