Can the radial artery be stented in a patient with hand ischemia due to a dialysis access fistula or focal radial‑artery stenosis?

Radial Artery Stenting in Dialysis-Associated Hand Ischemia

Yes, the radial artery can be stented when focal stenosis of the inflow artery is contributing to hand ischemia in dialysis patients, though this represents a limited and specific indication within a broader treatment algorithm. 1

Primary Treatment Context

Radial artery stenting is not a first-line intervention for dialysis-associated steal syndrome (DASS), but rather serves as an adjunctive endovascular option when specific anatomical lesions are identified. 1

When Radial Artery Stenting Is Appropriate

Angioplasty with or without stent placement of the radial artery is indicated when:

• Focal stenosis of the inflow radial artery is identified on fistulography that is contributing to inadequate perfusion of both the fistula and the hand 1
• The stenosis is proximal to the arteriovenous anastomosis and limiting flow 1
• Complete arteriography from aortic arch to palmar arch has been performed to identify all culprit lesions 1

The Endovascular Treatment Algorithm

For DASS with identified arterial stenosis:

1. Diagnostic fistulography must include complete arteriography with and without occlusion of the AV access to identify all stenotic segments 1

2. Angioplasty ± stenting of culprit stenoses in the radial artery (or other inflow vessels like subclavian or brachial arteries) can be performed to augment blood flow to both the fistula and hand 1

3. Combined procedures are often most effective: distal radial artery embolization combined with angioplasty of any ulnar artery stenoses may provide results equivalent to surgical DRIL procedures 1

Critical Distinction: Stenting vs. Embolization

The more common endovascular intervention for forearm/wrist fistula-related hand ischemia is distal radial artery embolization or ligation, NOT stenting. 1, 2

Distal Radial Artery Management

• Coil embolization or surgical ligation of the radial artery distal to the anastomosis eliminates the steal phenomenon by preventing retrograde flow 1, 2
• This approach showed 100% symptom improvement in endovascular coil embolization patients versus only 60% in surgical ligation patients 1
• Recent data demonstrates 82% symptom improvement with distal radial artery ligation (DRAL) while maintaining access function 2
• The 30-day complication risk is only 3.2% 2

Combined Endovascular Strategy

The optimal endovascular approach often combines:

• Distal radial artery embolization (to stop steal) 1
• PLUS angioplasty/stenting of any ulnar artery stenoses (to restore hand perfusion) 1, 3
• This leverages the robust collateral circulation between radial and ulnar systems 4

Important Caveats and Pitfalls

Technical limitations exist:

• Endovascular dilation is achievable in palmar arch arteries and distal forearm where surgical revascularization is routinely not possible 1
• However, the small diameter of distal radial and palmar vessels, especially with calcific disease, makes intervention technically challenging 1

Avoid these errors:

• Do not perform isolated procedures without complete arteriography—unrecognized proximal stenoses can cause access thrombosis post-intervention 1
• Do not delay intervention in symptomatic patients—progression from mild symptoms to tissue necrosis can occur rapidly 1
• Consider carpal tunnel syndrome in the differential diagnosis, as 7% of patients with suspected DASS actually have carpal tunnel as the culprit 2

Preservation Considerations

The radial artery should generally be preserved for future use as:

• A potential coronary artery bypass graft conduit 1
• Future vascular access for cardiac catheterization 1
• The presence of a functional arteriovenous fistula is listed as a contraindication to using the radial artery for transradial access procedures 1