title: Open repair and venous inflow plication of the arteriovenous fistula is effective in treating vascular steal syndrome.
abstract: BACKGROUND
  Vascular steal syndrome related to a dialysis arteriovenous fistula (AVF) can lead to symptoms of distal ischemia, limb loss, digit ulceration, and gangrene. Several complex procedures have been used to augment and restore distal limb perfusion while maintaining a functional AVF. We reviewed our experience in treating AVF-related vascular steal syndrome by simple plication of the initial AVF inflow segment.
  
  
  METHODS
  Clinical data of 26 patients (15 men; mean age, 58 years; range, 26-80) with vascular steal syndrome related to their AVF underwent plication during a 36-month period. There were 18 brachial-cephalic AVFs and 8 brachial-basilic AVFs with vein transposition. Relevant clinical variables, imaging studies, and treatment variables were analyzed.
  
  
  RESULTS
  Eighty-four percent of patients had hypertension, 62% were diabetics, and 15% had a previous limb or digit amputated. Hand pain, skin ulceration, or gangrene was present in 96%, 15%, and 12% of patients, respectively; 19% of patients had more than one symptom. Twelve (46%) patients had an aortic arch and upper extremity arteriogram, of which 67% showed evidence of arterial disease. One patient required percutaneous balloon-expandable stent treatment of a proximal left subclavian artery stenosis to improve flow. Duplex-derived volume flow measurements of the AVF were obtained with an average flow of 1.95 ± 0.83 L/min. Open repair and venous inflow plication was performed in all 26 patients. Average flow reduction in patients with preoperative and postoperative flow measurements was 0.6 ± 0.5 L/min (P < 0.05). There was a 12% revision rate within 3 months. Symptom resolution was achieved in 92% of patients while maintaining a functioning access out to 1 year. Two remaining patients who did not improve and proceeded to ligation of the AVF.
  
  
  CONCLUSIONS
  Surgical plication of the initial AVF inflow segment offers a simple solution to preserve the dialysis access and resolve symptoms related to vascular steal associated with high volume flow through the AVF.
authors.affiliation: Department of Cardiovascular Surgery, Houston Methodist Hospital, Weill-Cornell Medical College, Houston, TX.
authors.forename: Mitul S
authors.initials: MS
authors.lastname: Patel
authors.affiliation: Department of Cardiovascular Surgery, Houston Methodist Hospital, Weill-Cornell Medical College, Houston, TX.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
authors.affiliation: Department of Internal Medicine, Weill-Cornell Medical College, Dialysis Access Management Centers, Houston, TX.
authors.forename: George M
authors.initials: GM
authors.lastname: Nassar
authors.affiliation: Department of Cardiovascular Surgery, Houston Methodist Hospital, Weill-Cornell Medical College, Houston, TX; Department of Vascular & Endovascular Surgery, University Medical Center, Rizk Hospital, Lebanese American University (LAU), Beirut, Lebanon. Electronic address: joseph.naoum@umcrh.com.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Naoum
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000379:methods; D001783:Blood Flow Velocity; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012039:Regional Blood Flow; D006435:Renal Dialysis; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D034941:Upper Extremity / Q000098:blood supply*; D014680:Veins / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*