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.
Mount Sinai Medical School, New York, NY 10029, USA.
M
M
Haimov
H
H
Schanzer
M
M
Skladani
D000328:Adult; D000368:Aged; D001132:Arm / Q000098:blood supply*; D001164:Arteriovenous Fistula; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology* / Q000601:surgery; D008026:Ligation; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012189:Retrospective Studies; D016896:Treatment Outcome