What is the management plan for a diabetic patient with stage 4 hand necrosis and an Arteriovenous (AV) fistula site on the hand, who is on dialysis due to bilateral kidney failure (Impaired Renal Function)?

Management of Stage 4 Hand Necrosis with AV Fistula

This patient requires emergent referral to a vascular access surgeon for immediate intervention, as stage 4 ischemia (ulcers/necrosis/gangrene) represents a surgical emergency where delay can lead to catastrophic gangrene and hand amputation. 1

Immediate Actions

Emergent Surgical Referral

• Any patient with new or worsening ischemic findings must be referred to a vascular access surgeon emergently. 1
• Stage 4 ischemia with ulcers, necrosis, or gangrene indicates critical limb-threatening ischemia that progresses from slow deterioration over weeks to rapid final deterioration. 1
• Fingertip necroses are an alarming symptom requiring early intervention before rapid progression to gangrene occurs. 1

Diagnostic Evaluation Before Intervention

• Complete arteriography from aortic arch to palmar arch is mandatory before any surgical decision, as this is the most critical diagnostic tool. 1
• Perform imaging both with and without occlusion of the AV fistula to assess steal phenomenon and identify arterial stenoses. 1
• Noninvasive evaluation should include digital blood pressure measurement, duplex Doppler ultrasound, and transcutaneous oxygen measurement if available. 1
• The central objective is preserving the hand without sacrificing the fistula, but this requires knowing the complete arterial anatomy first. 1

Surgical Management Options

Primary Consideration: Fistula Ligation

• In stage 4 ischemia with tissue necrosis, immediate closure of the AVF may be mandatory to prevent limb loss. 1
• Ligation was required in 7 of 26 patients with access-related hand ischemia requiring intervention. 2
• One study reported below-elbow amputation in 1 patient and digital amputations in 5 patients despite intervention, highlighting the severity of this complication. 3

Alternative Surgical Techniques (If Arterial Anatomy Permits)

• Distal revascularization with interval ligation (DRIL) was the most common intervention (13 of 26 cases) in patients requiring surgical management of access-related hand ischemia. 2
• Banding procedures to reduce flow through the fistula (4 of 26 cases). 2
• Proximalization of arterial inflow (1 of 26 cases). 2
• Critical caveat: In the presence of hemodynamically significant arterial stenosis proximal to the fistula, banding procedures may cause access thrombosis due to perilous decline in blood flow. 1

Timing of Intervention

• Most interventions (63%) were performed >30 days after AVF creation, but 15% required intervention within 7 days. 2
• Urgent surgical intervention should be performed on all patients with stage 4 ischemia. 4

Risk Factors Present in This Patient

Diabetes as Major Risk Factor

• Diabetes is significantly associated with requiring intervention for access-related hand ischemia (odds ratio 13.62,95% CI 1.81-102.4, P=.011). 2
• Seventeen of 22 patients (77%) with ischemic or neurologic complications from upper extremity AV fistulas were diabetic. 3
• Diabetic patients have more pronounced arterial calcification, particularly in the wrist region. 1

Stage 4 Renal Disease Context

• Elder patients, those with hypertension, peripheral arterial occlusive disease, and diabetes are particularly prone to develop steal syndrome. 1
• The aging hemodialysis population with arterial changes from diabetes and hypertensive remodeling has increased the incidence of symptomatic peripheral ischemia to 1-4%. 1

Temporary Dialysis Access

• Fifty percent of patients with cutaneous necrosis requiring surgical intervention needed placement of a short-term hemodialysis catheter. 4
• Plan for alternative vascular access (tunneled dialysis catheter) as the hand fistula will likely require ligation or major revision. 4
• Avoid subclavian vein catheterization as it causes central venous stenosis and limits future access options. 1

Critical Pitfalls to Avoid

• Never delay intervention: One death occurred following massive hemorrhagic shock in a patient with cutaneous necrosis at the fistula site. 4
• Never perform surgical revision without complete arterial imaging: Failure to identify proximal arterial stenoses (such as subclavian artery occlusion) can lead to catastrophic outcomes after flow-reduction procedures. 1, 5
• Do not focus investigation only on the fistula: Subclavian artery occlusion and other proximal lesions are commonly missed when investigation is limited to the fistula site. 5
• Active bleeding occurred in 42.2% of patients with cutaneous necrosis, with 91% requiring blood transfusion. 4

Prognosis

• Intervention for access-related hand ischemia was not associated with AVF maturation failure in patients where the fistula could be salvaged (adjusted odds ratio 0.97, P=.95). 2
• However, with stage 4 ischemia, limb salvage takes absolute priority over access preservation. 1
• Recurrence occurred in 2 patients after initial intervention, requiring ongoing surveillance. 4