Proximalization of the arterial inflow: new treatment of choice in patients with advanced dialysis shunt-associated steal syndrome?

Dialysis-associated steal syndrome (DASS) is a potentially devastating complication. As a new surgical technique, proximalization of the arterial inflow (PAI) has been described recently to be of good effect in case of DASS. As there has not yet been much general familiarity with this technique, our aim with this prospective study was to establish its indication for a special group of patients who developed advanced DASS (finger necrosis) following autogenous hemodialysis access (HA). Twenty-three patients (18 brachial, five wrist HA) with advanced DASS underwent PAI. Graft material included either heparinized (13 patients) or nonheparinized (10 patients) polytetrafluoroethylene prosthetic material. Vascular function was evaluated pre- and postoperatively with duplex ultrasound. Procedural success was determined by restitution of limb circulation and preservation of the HA. In 15 cases (65%) symptoms of DASS disappeared completely, and in six patients (26%) adequate wound healing with improvement of symptoms was achieved. Symptoms were persistent in two patients (9%) who had tissue loss >1 cm at the fingertips. Overall there was a significant increase in radial artery flow velocity (from 35.65 +/- 7.69 to 55.21 +/- 8.51 cm/sec, p < 0.005) after PAI. A decrease of fistula flow (from 1.38 +/- 0.48 to 0.94 +/- 0.14 L/min, p = 0.003) was measured in patients with elbow HA but not in patients with wrist HA. Secondary patency after 18 months was 85%. PAI effected an improvement in distal radial artery circulation with an additional banding component in elbow HA. We found that PAI led to good clinical success, especially in patients developing small finger necrosis as a form of advanced DASS. However, in case of severe tissue loss (>1 cm in diameter), PAI was not successful (n = 2). In such situations, other treatment options have to be discussed.