AVF Dismantling Guidelines
Immediate AVF ligation (dismantling) is mandated when limb-threatening ischemia develops, including fingertip necrosis, gangrene, or monomelic ischemic neuropathy, as delay can result in catastrophic limb loss. 1
Absolute Indications for AVF Dismantling
Life-Threatening or Limb-Threatening Conditions
- Severe steal syndrome with tissue necrosis: When ischemic manifestations threaten limb viability, the fistula outflow must be ligated immediately 1
- Monomelic ischemic neuropathy: This acute neuropathy presents with global muscle pain, weakness, and a warm hand with palpable pulses starting within the first hour after AVF creation—immediate AVF closure is mandatory 1
- Progressive fingertip necrosis or gangrene: These alarming symptoms initially progress slowly over weeks but can rapidly deteriorate, requiring early intervention before catastrophic limb loss occurs 1
- Uncontrolled infection at the AV anastomosis: Very rare access infections at the anastomotic site require immediate surgery with resection of infected tissue; if the arterial segment must be resected, either an interposition vein graft or a more proximal new AV anastomosis may be created, but complete dismantling may be necessary if infection cannot be controlled 1
Severe Infection Requiring Access Removal
- Systemic sepsis from access infection: Untreated access infection can lead to bacteremia, sepsis, and death, requiring surgical exploration and removal of infected segments 2
- Metastatic infectious complications: Access-related bacteremia can cause metastatic complications that may necessitate complete access removal 1
Clinical Evaluation Before Dismantling Decision
Assessment of Ischemia Severity
The American Journal of Kidney Diseases provides staging for steal syndrome that guides intervention decisions 1:
- Mild symptoms (coldness, pain during dialysis): Occur in up to 10% of cases and often improve over weeks to months—dismantling not indicated 1
- Severe symptomatic ischemia: Pain, necrosis of fingertips, progressive tissue loss—requires urgent surgical intervention which may include dismantling 1, 2
High-Risk Patient Populations
Elderly patients, those with diabetes, hypertensive patients with peripheral arterial occlusive disease history, and patients with previous vascular surgery are at highest risk for developing steal syndrome requiring potential dismantling 1
Alternative Interventions Before Dismantling
Flow Reduction Techniques
- Proximal arterial stenosis dilation: If arterial stenoses proximal to the anastomosis are obstructing arterial inflow, angioplasty may be attempted (except in advanced arterial calcification) 1
- Flow reduction procedures: High-flow–induced steal syndrome requires decreased AVF flow volume, though traditional banding procedures have not been successful 1
Important caveat: These alternatives should only be attempted when ischemia is not immediately limb-threatening. Any delay in definitive treatment when tissue viability is at risk can lead to irreversible nerve injury and limb loss 2.
Timing Considerations
- Immediate action required: When fingertip necroses or gangrene develop, intervention must occur early as progression accelerates in the final stages 1
- No delay permitted: Clinical examination is mandatory, followed by ultrasound or radiological evaluation as necessary, with immediate referral to a vascular surgeon—delay can lead to catastrophic gangrene and hand amputation 1
Post-Dismantling Management
After AVF ligation for severe steal syndrome, alternative dialysis access must be established, typically requiring temporary catheter placement while planning for alternative permanent access in a different location or the contralateral limb 1.