What are the indications for Arteriovenous (AV) fistula ligation?

From the Guidelines

Arteriovenous (AV) fistula ligation is indicated in patients with severe ischemic steal syndrome or dialysis access steal syndrome (DASS) who are not candidates for other surgical interventions like DRIL (distal revascularization and interval ligation) or have failed other treatments. The decision to ligate an AV fistula is typically made after careful consideration of the patient's symptoms, vascular anatomy, and dialysis needs 1. Some key points to consider when evaluating a patient for AV fistula ligation include:

• The presence of severe ischemic symptoms such as pain, numbness, or tissue damage in the affected limb
• The failure of other surgical interventions like DRIL or banding to alleviate symptoms
• The presence of a functioning autologous fistula that can be preserved with alternative surgical techniques like DRIL 1
• The patient's overall health status and ability to undergo surgical intervention In general, ligation of an AV fistula should be considered a last resort, as it will result in the loss of the fistula as a dialysis access site. Alternative interventions like DRIL have been shown to be effective in resolving symptoms while preserving the fistula 1. However, in certain cases, ligation may be the only viable option to alleviate severe symptoms and prevent further complications. It is essential to weigh the potential benefits and risks of ligation and to consider the patient's individual needs and circumstances before making a decision 1. In cases where ligation is deemed necessary, it is crucial to have a plan in place for alternative dialysis access, such as creating a new fistula or graft, to ensure uninterrupted dialysis treatment.

From the Research

Indications for Arteriovenous (AV) Fistula Ligation

The indications for AV fistula ligation include:

• High-output cardiac failure 2, 3, 4, 5
• Dialysis-access steal syndrome (DASS) 3
• Aneurysmal fistula 2
• High-flow AVF with flow rates >2000 mL/minutes 5
• Cardio-pulmonary recirculation (Qa/CO) >20% 4
• Symptomatic high-flow AVF 2

Clinical Syndromes Associated with AV Fistula

Clinical syndromes associated with AV fistula that may require ligation include:

• Steal syndrome 2, 3
• High-output heart failure 2, 3, 4, 5
• Pulmonary hypertension 4, 5
• Distal ischemia 4

Treatment Options for High-Flow AVF

Treatment options for high-flow AVF include:

• Dynamic banding (DYBAND) technique 2
• Percutaneous AVF banding 3
• T-banding technique 6
• DRIL technique with interposition of a prosthetic patch 4
• Revascularization procedures such as distal inflow revision or RUDI 4
• Inflow banding at the anastomosis 5