Pathogenesis and management of upper-extremity ischemia following angioaccess surgery

Thirty-four patients with end-stage renal disease requiring hemodialysis developed over the course of 7 years (1987-1994) severe ischemia in the extremity carrying the angioaccess secondary to arterial 'steal'. Seven of these patients were treated with access ligation, 4 with banding reducing the flow through the access, and 23 with ligation of the artery distal to the inflow of the arteriovenous fistula and establishing of an arterial bypass from a point 5 cm proximal to the fistula to the distal artery. Of the 7 patients who underwent ligation, 5 had complete resolution of symptoms, 1 had persistent pain, and 1 patient had residual ischemic neuropathy. Of the 4 patients who underwent banding, 3 lost their access due to thrombosis shortly after the banding procedure, and in 1 patient partial resolution of symptoms was achieved. Of the 23 patients who underwent arterial ligation-bypass procedure, all showed immediate signs of improvement. One patient who presented with advanced gangrene eventually required amputation, and 3 patients had some residual symptoms. The cumulative patency of the access with this procedure was 73% at 1 year and 45.5% at 2 years. The patency for the bypass was 95.6% at 1 and 2 years. The arterial ligation-bypass procedure is currently the treatment of choice for patients developing severe ischemia secondary to 'steal' following construction of an arteriovenous fistula for dialysis.