Strategies for predicting and treating access induced ischemic steal syndrome

Access induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. A number of clinical risk factors have been identified to select patients at risk. Intraoperative measurement of the digital-brachial index may further distinguish at-risk patients when the DBI is <0.45. Once clinically significant steal has developed, surgical strategies to treat this problem should ideally reverse the ischemia while maintaining uninterrupted access for hemodialysis. To date, the distal revascularization-interval ligation or DRIL procedure has been the most consistently successful tactic in achieving these dual objectives. A number of alternative strategies have recently been proposed and will be discussed.