What is the best next dialysis access option for a patient with stage renal disease (End-Stage Renal Disease (ESRD)) and mild steal syndrome after a left brachioaxillary Arteriovenous (AV) graft, with limited venous options and a functional Peritoneal Dialysis (PD) catheter?

Best Dialysis Access Option for ESRD Patient with Mild Steal Syndrome

For this patient with ESRD who has a functional PD catheter and mild steal syndrome after a left brachioaxillary AV graft, the best next dialysis access option is to utilize the existing functional peritoneal dialysis catheter. 1

Assessment of Current Situation

• The patient has limited venous options with inadequate veins on the left and only one potentially adequate vein on the right (dominant arm) 1
• Current dialysis access includes:
  • Right internal jugular main tunnel dialysis catheter (currently in use)
  • Functional PD catheter (not currently being used)
  • Failed left brachioaxillary AV graft with mild steal syndrome 2
• The patient is right-hand dominant, which is an important consideration for future access planning 1

Recommended Access Strategy

Primary Recommendation: Utilize Functional PD Catheter

• The 2019 KDOQI guidelines recommend considering the patient's individualized ESKD Life-Plan when determining dialysis access options 1
• Since the patient already has a functional PD catheter, this should be the first-line option to preserve remaining vascular access sites 1
• Utilizing the PD catheter will:
  • Eliminate the need for immediate vascular access creation
  • Allow time for the steal syndrome to resolve
  • Preserve the remaining right-sided vein for potential future access if needed 1

Alternative Options (If PD Cannot Be Used)

If peritoneal dialysis is contraindicated or not feasible, consider the following options in order of preference:

1. Continue with the right internal jugular catheter temporarily while planning for more permanent access 1, 3

   • The right internal jugular is the preferred site for temporary dialysis access 3
   • This preserves the remaining right-sided vein for potential future AV access 1

2. Right-sided forearm early cannulation loop graft 1

   • Consider this option if long-term hemodialysis is anticipated and PD is not viable 1
   • A forearm loop graft is associated with lower risk of steal syndrome compared to upper arm or straight grafts 2

Management of Current Steal Syndrome

• Steal syndrome occurs in approximately 1-8% of patients with AV access, with higher risk in patients with:

  • Coronary artery disease 2
  • Peripheral arterial disease 2
  • Brachial artery inflow (as in this patient's case) 2
  • Straight graft configuration (as in this patient's case) 2

• For the current mild steal syndrome:

  • Monitor for worsening symptoms including pain, coldness, numbness, or tissue damage 4
  • If symptoms worsen, consider surgical revision options such as:
    • Distal revascularization with interval ligation (DRIL) procedure 2
    • Banding of the access 2
    • Access ligation if severe and unmanageable 2

Long-term Access Planning

• Regularly review and update the patient's ESKD Life-Plan quarterly 1
• If future vascular access is needed, consider:
  • Right-sided AV access with careful monitoring for steal syndrome 1, 2
  • Lower extremity AV access if upper extremity options are exhausted 1
  • HeRO graft as a last resort for patients with central venous stenosis 1

Monitoring and Follow-up

• Perform regular clinical assessment of the mild steal syndrome 4
• Digital-brachial index (DBI) less than 0.6 is predictive of symptomatic steal syndrome (100% sensitivity, 76% specificity) 5
• Monitor for signs of worsening ischemia, particularly during dialysis sessions 6
• Regularly assess the function of the PD catheter if this option is pursued 1

Important Considerations

• Avoid creating additional AV access in patients with risk factors for steal syndrome (coronary artery disease, peripheral arterial disease) unless absolutely necessary 2
• When creating future AV access, consider using smaller forearm arteries rather than the brachial artery to reduce steal risk 2
• Looped graft configurations are associated with lower risk of steal syndrome compared to straight grafts 2