Dilator-assisted banding and beyond: proposing an algorithm for managing dialysis access-associated steal syndrome.
OBJECTIVE
Dialysis access-associated steal syndrome (DASS) is a major complication of arteriovenous hemodialysis accesses. Although its underlying pathology is diverse, it is most often associated with excessive access flow. Dilator-assisted banding (DAB) is a simple flow-reduction technique that we described previously. This report is to illustrate the expansion of DAB and analyze the outcome of DAB in managing DASS.


METHODS
From February 2011 to April 2015, 30 patients underwent DAB for DASS. Their relevant clinical data were retrospectively reviewed or prospectively collected, and further analyzed statistically.


RESULTS
Of the 30 patients, 23 had an arteriogram and 3 required angioplasty ± stent placement for inflow artery stenosis. Besides intraluminal DAB (12/30), this report also included extraluminal DAB (14/30) and open fistula reduction plus DAB (4/30). After DAB, the severity scores of DASS were reduced from 2.8 ± 0.4 to 0.2 ± 0.4 for the fistula group (n = 24, p&lt;0.001) and from 3.0 ± 0.0 to 1.2 ± 1.2 for the graft group (n = 6, p = 0.041). DAB was effective in all but two graft patients who subsequently underwent proximalization of arterial inflow (PAI) that resulted in resolution of DASS. During follow-up of 18.7 ± 14.5 months (range 1-50), all accesses remained functional. At 24-months post-DAB, the primary patency, primary-assisted patency and secondary patency rates of the fistula group were 72%, 91% and 100%, respectively.


CONCLUSIONS
DAB is a simple, effective and versatile approach for managing DASS. PAI may be employed for rescue or as primary choice when banding is ineffective. Based on our data and the literature, an algorithm is proposed for managing DASS.
AKDHC Access Centers, Arizona Kidney Disease and Hypertension Center, Phoenix, Arizona - USA.
Shouwen
S
Wang
Division of Nephrology and Hypertension, Albany Medical College, Albany, New York - USA.
Arif
A
Asif
Department of Surgery, University of Oklahoma-Tulsa, Tulsa, Oklahoma - USA.
William C
WC
Jennings
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000800:Angioplasty, Balloon / Q000295:instrumentation; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D001783:Blood Flow Velocity; D019091:Critical Pathways; D004106:Dilatation / Q000295:instrumentation; D004867:Equipment Design; D005260:Female; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D008026:Ligation; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012039:Regional Blood Flow; D006435:Renal Dialysis; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency