Abstract
Patients with dialysis access steal phenomenon can present with pain, paresthesia, ulceration, and tissue loss of the digits. Some degree of steal is common, up to 80% of patients with a radiocephalic arteriovenous fistula have mild, asymptomatic arterial steal documented by a decreased digital blood pressure. Critical ischemia of the upper extremity is a rare condition compared with ischemia of the lower extremities. High-flow arteriovenous fistulas have a greater risk of steal than normal flow arteriovenous fistulas; however, combined with arteriosclerotic disease they may also lead to ischemia. There are several strategies to prevent arterial steal following hemodialysis access that should be used; preoperative testing to identify proximal arterial lesions, upper extremity vein mapping and sizing, Allen's test (radial artery patency), end-to-side arteriovenous anastomosis to decrease steal and distal venous hypertension, selective venous arterialization at the elbow with ligation of deep perforation branch to improve maturation and restrict flow, and stepped or tapered grafts to limit flow. A noninvasive upper extremity arterial Doppler diagnosis is of importance to determine treatment options for patients. The goal of the vascular access surgeon is to promptly recognize and treat the disorder to maximize both limb and access salvage.
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