Management of Steal Syndrome Post AV Graft Placement
If ischemic manifestations threaten limb viability, immediately ligate the fistula outflow and arrange urgent surgical consultation; for less severe cases, the treatment approach depends on the underlying cause—arterial stenoses proximal to the anastomosis should be treated with angioplasty, while high-flow induced steal requires flow reduction procedures, with DRIL being the preferred surgical option for upper arm accesses and endovascular coil embolization for forearm accesses. 1, 2
Immediate Assessment and Risk Stratification
Assess severity of ischemia immediately to determine urgency of intervention. Hand discoloration and loss of sensation indicate Stage III or IV steal syndrome, requiring urgent intervention to prevent permanent tissue damage and limb loss 2. Look specifically for:
- Stage III: Pain at rest, hand discoloration, sensory changes 2
- Stage IV: Ulcers, necrosis, or gangrene—this is limb-threatening and requires emergency intervention 2
- Monomelic ischemic neuropathy: Particularly in older diabetic patients with elbow/upper-arm AVFs, which requires immediate AVF closure 2
Obtain digital-brachial index (DBI) measurement on the day of surgery if possible. A DBI <0.6 has 100% sensitivity and 100% negative predictive value for symptomatic steal, helping identify patients requiring intervention 3.
Diagnostic Workup
Perform fluoroscopy fistulography and duplex ultrasound as complementary procedures to identify the underlying cause 1, 2. These studies should evaluate:
- Arterial stenoses proximal to the anastomosis 1
- Ulnar artery patency and flow 1
- Palmar arch anatomy 1
- Access flow rates 1
Comprehensive arteriography is the gold standard to identify arterial stenoses or occlusions and guide treatment planning 2.
Treatment Algorithm Based on Severity and Etiology
Emergency Management (Stage IV - Limb-Threatening Ischemia)
Immediately ligate the fistula outflow when ischemic manifestations threaten limb viability 1. This is non-negotiable for tissue preservation.
Place a temporary tunneled dialysis catheter as bridging therapy to maintain hemodialysis access, recognizing this carries increased infection risk and higher mortality but is necessary 1, 2.
Urgent Management (Stage III - Severe Symptoms)
For Arterial Stenosis-Related Steal:
Perform angioplasty of proximal arterial stenoses obstructing arterial inflow, but avoid this approach in advanced general arterial calcification where it will fail 1, 2.
Consider combined endovascular approach: Distal radial artery coil embolization plus recanalization and angioplasty of ulnar artery stenoses/occlusions may provide results equivalent to DRIL 1.
For High-Flow Induced Steal:
Location-specific surgical approach:
Upper arm fistulae: DRIL (Distal Revascularization-Interval Ligation) is the preferred procedure, achieving superior fistula preservation (100%) compared to banding (89%) and equal symptom resolution (98%) compared to ligation with no increase in complications 1, 4, 5. DRIL involves ligating the brachial artery distal to the fistula anastomosis and placing a vein bypass to restore distal perfusion 1, 2.
Forearm fistulae: Endovascular coil embolization of the distal radial artery is preferred due to diminutive vessel caliber and severe calcifications that make surgical revascularization technically difficult 1, 2. This can be performed during the same session as diagnostic angiography 1.
Alternative surgical options include:
- RUDI (Revision Using Distal Inflow): 95% fistula preservation, can use basilic vein graft 6, 5
- PAI (Proximalization of Arterial Inflow): Less invasive option 4, 5
- Distal radial artery ligation 4, 5
What NOT to Do
Avoid traditional banding procedures as they have a high failure rate (62%) and are the most common cause for reintervention (73% of failures) 1, 2, 4, 5. While banding may be considered, it has inferior outcomes compared to DRIL.
Do not delay intervention when symptoms are progressive, as fingertip necrosis can rapidly deteriorate and early intervention prevents severe injuries and tissue loss 2.
Post-Intervention Monitoring
Monitor for recurrence as steal syndrome can develop months to years after AVF creation in approximately 25% of patients 2.
Assess for progressive arterial disease requiring ongoing surveillance 2.
Watch for infection at any surgical or intervention site, initiating immediate broad-spectrum antibiotic therapy (vancomycin plus aminoglycoside) if suspected, with treatment duration of 6 weeks for graft infections 1, 2.
Special Considerations
Gender differences exist: Women are less likely to receive DRIL but more likely to undergo ligation, though this may represent bias rather than optimal care 5.
Timing matters: Ligation and banding are typically performed acutely (median 24-39 days post-access creation), while DRIL and RUDI are performed later (median 97-100 days) 5.
Consider proximal radial artery (PRA) as inflow source for future access creation, as it accounts for only 2% of steal cases despite being used in 18% of fistulas 4.