Ischemic steal syndrome: a case series and review of current management

Currently over 5000 patients are receiving hemodialysis in Australia, which is an increase by approximately 7% each year. Distal ischemia secondary to the steal syndrome (ISS) is an uncommon but recognized complication. Several methods are now available to manage this problem including ligation, banding, and distal revascularization with interval ligation (DRIL). The aim of this report is to review the experience of the authors on this complication and its management at Royal Perth Hospital.

The Vascular Physiology Laboratory Database was used to identify those patients referred for investigation of ISS. Data were collected retrospectively from these patients' files concerning their demographics, graft particulars, and type of interventional procedure. Patients were then recalled to assess long-term patency and current venous access and for postoperative vascular studies.

Eighteen people were identified with ischemic symptoms. The mean age was 66 (range, 44 to 82). Fourteen (77.8%) were men, and 15 (83.3%) were diabetic. Renal failure was secondary to diabetes in 8 patients, hypertension in 3, and a combination of both in 7 patients. Intervention was via the DRIL procedure in 12, ligation in 5, and banding in 1. One patient underwent angioplasty of the ulnar artery before DRIL. At follow-up (between 1 and 12 months), all DRIL bypass were patents. The 5 ligated patients all improved, and the patient who underwent banding thrombosed their graft.

The DRIL procedure should be considered the standard operation to manage ISS in that it manages the ischemia while maintaining the functional fistula. It is, however, still necessary to ligate some fistulae and seek alternative access. There are still no preoperative indicators as to who will suffer ISS.