Diagnosing dialysis access steal syndrome using skin perfusion pressure with an occlusion balloon

A 76 year-old male with end-stage renal disease on hemodialysis (HD) presented with a non-healing ulcer on his right foot. His access site was the anterior tibial artery to great saphenous vein graft in the right lower distal extremity. Angiography showed so much flow through the dialysis access that distal extremity flow seemed inadequate. These symptoms are often caused by dialysis access steal syndrome (DASS), but many HD patients also have atherosclerotic disease. We used an occlusion balloon to temporarily occlude shunt flow and found that the skin perfusion pressure (SPP) increased significantly in both the dorsal and plantar arteries. Measuring the SPP under balloon occlusion allowed for a definitive diagnosis of DASS.