From the Guidelines
Necrosis of the finger in a patient with a dialysis fistula is likely due to steal syndrome, which requires urgent medical attention, and treatment options include fistula banding, revision surgery, or fistula ligation depending on severity, as recommended by the most recent study 1.
Causes and Risk Factors
The condition occurs when blood is diverted from the hand to the fistula, causing inadequate blood supply to the fingers. Steal syndrome develops because the arteriovenous fistula creates a low-resistance pathway that diverts blood away from the normal circulation to the hand. Risk factors include diabetes, peripheral vascular disease, and certain fistula configurations.
Diagnosis and Treatment
Patients should seek immediate medical care at an emergency department or contact their vascular surgeon or nephrologist. Diagnostic arteriography of the extremity and the entirety of its inflow is a foundational part of the diagnostic evaluation prior to determining management, as stated in 1.
Management
While waiting for medical care, patients should keep the affected hand warm, avoid cold exposure, and refrain from smoking which worsens blood flow. They should not compress the fistula as this may cause clotting. Endovascular management, including angioplasty or stenting of the culprit lesion, may offer therapeutic benefit and thus relief of the patient’s ischemic symptoms, as suggested by 1.
Importance of Early Intervention
Early intervention is critical to prevent permanent tissue damage, as progressive necrosis can lead to finger amputation if left untreated. The central objective in treating a patient with hemodialysis presenting with hand ischemia is to preserve the digits and hand without sacrificing the vascular access, as recommended by 1.
- Key points to consider:
- Steal syndrome is a critical complication in patients receiving long-term hemodialysis
- Early intervention is crucial to prevent permanent tissue damage
- Treatment options include fistula banding, revision surgery, or fistula ligation depending on severity
- Endovascular management may offer therapeutic benefit and relief of ischemic symptoms
- Patients should seek immediate medical care if they experience symptoms of steal syndrome.
From the Research
Phenomenon of Necrosis
- The phenomenon of necrosis to the finger to the arm that has a dialysis fistula is a serious complication that can occur in patients undergoing hemodialysis 2.
- This condition is often referred to as "steal syndrome" or "distal hypoperfusion ischemia syndrome" and is caused by the diversion of blood flow from the arm to the dialysis fistula, resulting in ischemia and potential tissue necrosis 2.
Risk Factors
- Patients with a dialysis fistula are at risk of developing this condition, particularly if the fistula is located in the upper arm 2.
- Other risk factors include the presence of a central venous catheter or arteriovenous graft, as well as underlying medical conditions such as diabetes and hypertension 3, 4, 5, 6.
Prevention and Treatment
- Prevention of infection is crucial in reducing the risk of necrosis, and can be achieved through the use of antibiotics and proper wound care 3, 4, 5.
- Treatment of distal hypoperfusion ischemia syndrome typically involves a minimally invasive banding procedure to reduce blood flow to the fistula and alleviate symptoms 2.
- In severe cases, access ligation may be necessary to prevent further tissue damage and necrosis 2.