title: Arterial pressure gradient of upper extremity arteriovenous access steal syndrome: treatment implications.
abstract: OBJECTIVE
  Treatment options after arteriovenous fistula (AVF) associated steal include ligation, banding, and distal revascularization-interval ligation (DRIL). The purpose of this study was to evaluate the arterial pressure gradients in upper extremity steal syndrome.
  
  
  METHODS
  Preoperative arteriography and sequential intra-arterial pressure readings were performed on consecutive AVF patients with hand ischemia. Analysis of variance (ANOVA) with repeated measures analyzed intersubject comparisons, and post hoc analysis identified anatomic locations with highest inflow pressures.
  
  
  RESULTS
  Nine patients presented with ischemic hand symptoms after AVF. Pullback arterial pressure measurements revealed gradual increases in systolic and mean pressures as the catheter position was moved proximally from the AVF anastomosis. Post hoc analysis after ANOVA revealed higher axillary artery systolic pressure compared to proximal brachial artery (153 vs 116.8, P = .007).
  
  
  CONCLUSIONS
  AVF-related steal syndrome decreases arterial inflow pressure of the affected extremity more proximally than previously thought. When performing a DRIL procedure, consideration should be given to placing the anastomosis as proximally as possible.
authors.affiliation: Division of Vascular Surgery, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA. treifsn1@jhmi.edu
authors.forename: Thomas
authors.initials: T
authors.lastname: Reifsnyder
authors.forename: George J
authors.initials: GJ
authors.lastname: Arnaoutakis
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D001366:Axillary Artery / Q000503:physiopathology / Q000601:surgery*; D015142:Baltimore; D001794:Blood Pressure; D001916:Brachial Artery / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D008026:Ligation; D008875:Middle Aged; D011446:Prospective Studies; D011859:Radiography; D012039:Regional Blood Flow; D006435:Renal Dialysis; D012086:Reoperation; D034941:Upper Extremity / Q000098:blood supply*