What's the next step for a patient with impaired renal function and a newly occluded left brachial artery to axillary vein (AV) graft, who also has mild steal syndrome, after a recent dialysis access mapping showed limited vascular options?

Management of Occluded AV Graft with Mild Steal Syndrome

For a patient with an occluded left brachial artery to axillary vein AV graft and mild steal syndrome, urgent endovascular thrombectomy with angioplasty of any underlying stenosis should be performed to restore graft patency while addressing the steal syndrome.

Immediate Management of Occluded AV Graft

• Thrombosis of an AV graft requires immediate evaluation and intervention, as early treatment increases the likelihood of successful restoration of patency and avoids the need for a temporary catheter 1
• Delay in treatment can lead to progressive growth of the thrombus, making interventional procedures more difficult and reducing long-term success rates 1
• Percutaneous thrombectomy with angioplasty of the underlying stenosis is the first-line treatment with success rates greater than 90% 1

Specific Intervention Approach

• Perform endovascular thrombectomy using mechanical methods (dilation and aspiration), thrombolytic agents, or a combination of both 1, 2
• During the procedure, evaluate for and treat any venous outflow stenosis (present in approximately 74% of cases) and arterial inflow stenosis (present in approximately 4.5% of cases) 2
• High-pressure balloons (25-30 atmospheres) may be needed for resistant venous stenoses 1
• Consider stent placement only if there is acute elastic recoil of the vein (>50% stenosis) after angioplasty or if stenosis recurs within a 3-month period 1

Addressing the Steal Syndrome

• The presence of mild steal syndrome (Stage I-II) should be carefully evaluated but does not necessarily require immediate intervention beyond the thrombectomy 1
• Mild steal syndrome (coolness, paresthesia without rest pain) often improves over weeks to months in up to 10% of cases 1, 3
• Monitor for progression of steal syndrome symptoms, as they can worsen over time and may require additional intervention 1, 4

Follow-up and Monitoring

• Schedule follow-up within 1-2 weeks after the procedure to assess graft patency and steal syndrome symptoms 5
• Implement a regular surveillance program to detect recurrent stenosis or thrombosis 1
• Be aware that approximately 25% of declotted grafts may require repeated percutaneous thrombectomy within 30 days 2

Considerations for Worsening Steal Syndrome

• If steal syndrome worsens to Stage III (rest pain) or Stage IV (ulcers/necrosis/gangrene), consider more definitive surgical interventions 1, 5
• Options for severe steal syndrome include:
  • Distal Revascularization with Interval Ligation (DRIL) - provides 98% symptom improvement while preserving the access 5
  • Revision Using Distal Inflow (RUDI) - 95% access preservation with 37% complication rate 5
  • Banding - 89% access preservation but higher complication rate (49%) and lower symptom improvement (75%) 5
  • Ligation - only as a last resort when other options fail or are contraindicated 5

Special Considerations

• The right internal jugular tunnel dialysis mapping showed limited vascular options, making preservation of the current access particularly important 1
• Patients with diabetes are at higher risk for progression of steal syndrome and require closer monitoring 6, 4
• Evaluate for central venous stenosis, which can exacerbate steal syndrome symptoms and cause extremity edema 6

Pitfalls to Avoid

• Do not delay intervention, as this increases the risk of permanent thrombus organization and reduces success rates 1
• Avoid placing a new tunneled dialysis catheter if possible, as catheters can lead to central venous stenosis in up to 50% of cases 1
• Do not perform banding as a first-line treatment for steal syndrome as it has lower success rates and higher complication rates compared to other procedures 5
• Differentiate true steal syndrome from carpal tunnel syndrome, tissue acidosis, or edema from venous hypertension before planning interventions 1