m mazen hachem *, md, phd, facs., m bosaeed * and m wakka * * division of vascular surgery
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
M Mazen Hachem*, MD, PhD, FACS., M Bosaeed* and M Wakka* *Division of Vascular SurgeryKing Abdul-Aziz Medical City
Jeddah, KSA
Upper Limb Ischemia After Vascular Access Surgery
Differential Diagnosis and Management
Ischemic Complications of VA• 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
Duncan et al., JVS 4: 144, 1986Odland et al., Surgery 110:664, 1991
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
Ischemic Complications of VAIschemic Monomelic Neuropathy
• IMN results from blood flow alteration to vasa nervosum of Median, Radial & Ulnar nerves producing claw hand. Regardless of VA flow.– Irreversible even with
appropriate strategy and early intervention.
• Absence of severe tissue ischemia differentiate IMN from ISS.
Objectives1. Recognize clinical presentations – Ischemic Steal Syndrome– Ischemic Monomelic Neuropathy
2. Be familiar with treatment options3. Select appropriate treatment options for
each case.
Ischemic Steal Syndrome Ischemic Monomelic Neuropathy
Predominant feature Cold hand with pain onor off dialysis
Weakness and paralysisof muscles withprominent sensory loss
Onset Acute and chronic Immediately
Access type Common with upperarm but also seen withforearm accesses
Only in proximal access
Sex Variable Female>Male
Tissue involved Skin > muscle > nerve NervesCause Vascular insufficiency
leading to distalhypoperfusion
Vascular insufficiencycausing nerve damage
Radial pulse Usually diminished or absent Usually presentDiagnostic evaluation History,/ physical examination,
and arteriographyHistory and the clinicalfeatures
More prevalent in Patients with diabetes,peripheral vasculardisease, smokers
Patients with diabetes,peripheral vascularDisease + PN
Management strategies Percutaneous and orSurgery
Access ligation?????
Ischemic Steal Syndrome Diagnosis
• History/ Physical examination– Coldness– Radial pulse W/O access
occlusion– Motor weakness &
Sensory deficit– Trophic changes (late
SS).
Ischemic Steal Syndrome Diagnosis
• 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
Grading of Ischemic Steal SyndromeGrade Symptoms Management
0 Asymptomatic Nothing
I Cold hand with tolerable symptomsFlow augmentation by access occlusion
Observation
II Ischemic symptoms during dialysis“Claudication”
Non-Invasive StudyMedical + Angiogram PTA/ Surgery
III Rest pain / Tissue loss Angiogram & proceed
Ischemic Steal Syndrome Goals of Treatment
• Restore perfusion to the hand• Maintain Vascular Access
Ischemic Steal Syndrome Treatment Options
• Do nothing• PTA• Surgery
1. Access ligation2. Banding3. Distal Revascularization-Interval Ligation (DRIL)4. Distalizaion of arterial inflow (RUDI)5. Proximalization of arterial inflow (RUPI)6. Minimally Invasive Limited Ligation Endoluminal-
Assisted Revision (MILLER)
Treatment Options
• Restore perfusion• Lost Vascular Access
• “Blind” banding w/o consideration of access flow is ineffective and ill-advised.
Access Ligation Banding
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 fistulawith distal artery ligation and revascularization. J Vasc Surg 7: 770–773, 1988
mmhachem 2006-2007
Brachial artery
Brachial-to-brachial bypass
Cephalic vein
Anastomosis site
Interval ligation
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
Treatment Options
• Increase distal flow• Eliminate steal
phenomena due to high graft resistant
• Resolved ischemia
RUPI Procedure
J Zanow, U Kruger, H Schlz: Proximalization of arterial inflow: A new technique to treat access-related ischemia;J Vasc Surg, 43:1216-1221, 2006
Treatment Option
Minimally InvasiveLimitedLigationEndoluminal assistedRevision
Gregg A. Miller, MD. 2006
What’s a MILLER Outpatient Procedure
MILLER Procedure
ACCESS FLOW MEASURMENTTreatment Options Guideline
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
RESULTS
Authors Year Proc. No. Pt. Results
De Caprio 1997 Banding 18 100% ischemia resolved1/11 AVG patent at 6 m0/7 AVF patent at 30 D
Haimovici 1996 DRIL 34 100% ischemia resolved73% AVG patency at 1 year96% bypass patency at 1 year
Hachem 2006 DRIL 16 90% ischemia resolved87.5% VA patency at1 year81% bypass patency at 1year
Zanow 2006 RUPI 30 80% ischemia resolved90% patency
MILLER 2010 MILLER 114 96% ischemia resolved90% patency at 1 year
Minion 2005 RUDI 6 100% ischemia resolved100% patency 14m
Minion 2005 RUPI 4 100% ischemia resolved100% patency at 1 year
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
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
Thank You