Holding Pressure: AV Fistula/Graft Complications Part 1

Guest:

Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine.

He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic.

 

Resources: 

• Rutherford Chapters (10th ed.): 174, 175, 177, 178

• Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/

• The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext 

• KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/ 

 

Outline:

1. Steal Syndrome

• Definition & Etiology

• Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand.

• Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow. 

• Incidence and Risk Factors

• The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice

• Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits.

• Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4 

• Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries’ ability to vasodilate and adjust to decreased blood flow.

• Patient Presentation, Symptoms, Grading

• Steal syndrome is diagnosed clinically. 

• Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation.

• Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of