What causes hand weakness after intravenous (IV) arteriovenous fistula placement?

From the Guidelines

Hand weakness after IV fistula placement is a medical emergency that requires immediate attention, as it may indicate vascular steal syndrome, nerve compression, or damage, and prompt evaluation and treatment are crucial to prevent permanent weakness or disability. The condition can occur due to the shunting of arterial blood flow through the AV access and away from the peripheral system, resulting in a constellation of signs and symptoms, ranging from mild digital numbness to severe motor impairment 1. The prevalence of this entity ranges from 1% to 20%, and it usually manifests as hand pain during and off dialysis, and less commonly as loss of function or tissue death 1.

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 1. Diagnostic arteriography of the extremity and the entirety of its inflow is a foundational part of the diagnostic evaluation prior to determining management 1. Treatment options may include endovascular intervention, such as angioplasty or stenting of the culprit lesion, which can offer therapeutic benefit and relief of the patient's ischemic symptoms 1. In some cases, endovascular occlusion of the hemodialysis access using vascular plugs may be necessary to manage the problem 1.

Key considerations in management include:

• Immediate medical attention to prevent permanent weakness or disability
• Diagnostic arteriography to evaluate the extent of the condition
• Endovascular intervention, such as angioplasty or stenting, to relieve ischemic symptoms
• Endovascular occlusion of the hemodialysis access using vascular plugs as an alternative to surgical ligation
• Preservation of the digits and hand without sacrificing the vascular access as the central objective of treatment 1.

The sooner the evaluation and treatment are initiated, the better the chances for complete recovery, and prompt medical attention is essential to prevent permanent weakness or disability.

From the Research

Hand Weakness after IV Fistula Placement

• Hand weakness after IV fistula placement can be attributed to various factors, including regional ischemia and hemodynamic perturbations 2.
• A study published in 2017 found that six weeks following AVF placement, a significant decrease in access side digital pressures was observed, with only partial recovery at 6 months, and grip strength was significantly worse in the access side limb 2.
• Another study published in 2023 reported a case of ischemic monomelic neuropathy (IMN) after arteriovenous fistula placement, which presented with severe pain, weakness, and loss of sensation in the affected arm, highlighting the importance of prompt diagnosis and timely vascular interventions 3.

Mechanisms and Risk Factors

• The exact mechanisms of hand weakness after IV fistula placement are not fully understood, but it is believed that ischemia alone does not completely explain access-related hand dysfunction 2.
• Nerve conduction parameters and biomechanical parameters were found to be relatively independent of hemodynamic parameters, suggesting that other factors may contribute to hand weakness 2.
• The use of antiplatelet agents, such as clopidogrel and aspirin, may reduce the risk of thrombosis and major ischemic events, but may also increase the risk of major hemorrhage 4, 5.

Diagnosis and Treatment

• Diagnosis of hand weakness after IV fistula placement should involve a comprehensive evaluation of hand function, including grip strength, dexterity, sensation, and perception of hand function 2.
• Treatment of hand weakness after IV fistula placement may involve vascular interventions, such as fistula ligation, and medical management with antiplatelet agents and other medications 3, 5.
• Further research is needed to elucidate the alternative mechanisms of hand weakness after IV fistula placement and to develop effective treatment strategies 2.