title: A Case of Brachiocephalic Fistula Steal and the Emergency Physician's Approach to Hemodialysis Arteriovenous Fistula Complications.
abstract: BACKGROUND
  Chronic kidney disease is common in the United States, with many patients maintained on hemodialysis (HD). The process of HD requires vascular access through an arteriovenous (AV) fistula, AV graft, or central venous catheter. Today, as a result of the National Kidney Foundation's "Fistula First" initiative, nearly 55% of HD patients utilize an AV fistula. As there is significant morbidity and mortality associated with fistula placement and recurrent fistula cannulation, emergency physicians must be equipped to recognize and treat fistula complications.
  
  
  OBJECTIVE
  To detail a case study of vascular insufficiency (vascular steal) presenting to an emergency department (ED) and provide an evidence-based approach to the emergency assessment and management of HD AV fistula complications.
  
  
  CONCLUSIONS
  A 66-year-old man presented to the ED with left upper extremity pain, paresthesias, and loss of grip strength of 1-week duration 15 days after placement of left upper extremity brachiocephalic fistula. He was diagnosed with dialysis access-associated steal syndrome and taken to the operating room for revision. Patients with HD fistulas may experience several complications, including vascular insufficiency, hemorrhage, infection, stenosis, thrombosis, aneurysms, or pseudoaneurysms. Emergency physicians must be able to identify these complications and deliver timely treatment.
  
  
  CONCLUSIONS
  A comprehensive understanding of the appropriate management of AV fistula complications is paramount for the emergency physician. Early recognition and treatment of vascular insufficiency resulting from fistula creation, fistula hemorrhage, fistula infection, stenosis, thrombosis, and aneurysms or pseudoaneurysms is vital to reducing the morbidity and mortality associated with HD.
authors.affiliation: Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas.
authors.forename: Erica
authors.initials: E
authors.lastname: Simon
authors.affiliation: Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas.
authors.forename: Brit
authors.initials: B
authors.lastname: Long
authors.affiliation: Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas; Baylor College of Medicine, Houston, Texas.
authors.forename: Kyle
authors.initials: K
authors.lastname: Johnston
authors.affiliation: Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas.
authors.forename: Shane
authors.initials: S
authors.lastname: Summers
mesh_terms: D000368:Aged; D017541:Aneurysm, False / Q000209:etiology; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000592:standards; D004636:Emergency Service, Hospital / Q000458:organization & administration; D018737:Hand Strength / Q000502:physiology; D006801:Humans; D008297:Male; D010292:Paresthesia / Q000209:etiology; D006435:Renal Dialysis / Q000009:adverse effects / Q000295:instrumentation*; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000628:therapy*; D013927:Thrombosis / Q000209:etiology
keywords: arteriovenous (AV) fistula; fistula aneurysm; fistula pseudoaneurysm; hemodialysis; hemodialysis fistula infection; vascular steal