How to manage steal syndrome in a patient with Chronic Kidney Disease (CKD) stage 5 due to an Arteriovenous (AV) fistula?

Management of Steal Syndrome in CKD Stage 5 Patients with AV Fistula

For CKD stage 5 patients with steal syndrome, immediate diagnostic imaging with fluoroscopy fistulography and duplex ultrasound should be performed, followed by DRIL (Distal Revascularization-Interval Ligation) surgery for upper arm fistulae or endovascular coil embolization for forearm fistulae, with fistula ligation reserved only for limb-threatening ischemia. 1

Immediate Diagnostic Evaluation

Initial imaging is critical and should include both modalities:

• Perform fluoroscopy fistulography AND duplex Doppler ultrasound together as complementary procedures to identify the underlying cause of steal syndrome 1, 2
• Look for reversal of blood flow distal to the arterial anastomosis or bidirectional flow on duplex ultrasound 3
• Complete arteriography from aortic arch to palmar arch reveals arterial stenoses in 62% of patients with suspected steal syndrome 3
• Assess for inflow arterial stenosis, outflow stenosis, high fistula flow, or combinations of these causes 4, 5

Clinical severity staging guides urgency:

• Stage I: Pale/blue/cold hand without pain 2
• Stage II: Pain during exercise or hemodialysis 2
• Stage III: Pain at rest 2
• Stage IV: Ulcers, necrosis, or gangrene requiring emergency intervention 2

Treatment Algorithm Based on Fistula Location and Severity

For Upper Arm (Brachial Artery) Fistulae

DRIL is the preferred surgical approach:

• DRIL involves ligation of the brachial artery distal to the fistula anastomosis and placement of a vein bypass to restore distal perfusion 1
• DRIL achieves superior fistula preservation compared to banding (which has 62% failure rate) and equivalent symptom resolution to ligation but with better access preservation 1
• Surgical consultation should be obtained immediately when steal syndrome is suspected in upper arm fistulae 1

Alternative surgical options for upper arm fistulae:

• Proximalization of arterial inflow 1
• Revision using distal inflow 1
• Avoid banding procedures due to high failure rates (62%) and frequent need for reintervention (73% of failures) 1

For Forearm (Radiocephalic) Fistulae

Endovascular coil embolization is the preferred approach:

• Distal radial artery coil embolization combined with recanalization and angioplasty of ulnar artery stenoses provides results equivalent to DRIL 1
• Endovascular treatment is superior for forearm fistulae due to diminutive vessel caliber and severe calcifications that make surgical revascularization technically difficult 1
• Coil embolization can be performed during the same session as diagnostic angiography 1, 6, 7
• This approach allows treatment of additional stenoses and augments blood flow to both the fistula and hand 1

Surgical ligation as alternative:

• Simple distal radial artery ligation is an option but shows inferior results compared to endovascular coil embolization (improvement in 3 of 5 patients with ligation versus 10 of 10 with coil embolization) 1

For Limb-Threatening Ischemia (Stage IV)

Emergency fistula ligation is required:

• Immediate surgical consultation for fistula ligation when ulcers, necrosis, or gangrene are present 2
• Place temporary tunneled dialysis catheter as bridging therapy to maintain hemodialysis access 1, 2
• Recognize that tunneled catheters carry increased infection risk and higher mortality but are necessary temporizing measures 1

Treatment of Underlying Arterial Disease

Address arterial stenoses when identified:

• Angioplasty or stenting of arterial stenoses proximal to the anastomosis may resolve steal syndrome in patients with hemodynamically significant stenosis 3, 2, 5
• This should be the first treatment option when stenosis is identified as the primary cause 4, 5
• Avoid angioplasty in cases of advanced arterial calcification 2

Critical Pitfalls to Avoid

Monitor for monomelic ischemic neuropathy:

• This devastating complication occurs particularly in older diabetic patients with elbow/upper-arm AVFs 2
• Requires immediate AVF closure to prevent permanent nerve damage 2

Do not delay intervention:

• Fingertip necrosis and tissue loss can rapidly deteriorate if treatment is delayed 2
• Hand discoloration and loss of sensation indicate Stage III or IV disease requiring urgent intervention 2

Avoid traditional banding:

• Banding has historically shown poor success rates and high reintervention needs 1, 2

Post-Treatment Surveillance

Long-term monitoring is essential:

• Steal syndrome can recur or develop months to years after AVF creation in approximately 25% of patients 2
• Progressive arterial disease may require ongoing surveillance 2
• Monitor for signs of infection and initiate broad-spectrum antibiotics if necessary 2