Revision Using Distal Inflow: A Novel Approach to Dialysis-associated Steal Syndrome

Current access-preserving treatment options for dialysis-associated steal syndrome (DASS) include fistula lengthening or banding and distal revascularization interval ligation (DRIL). We describe a novel technique for the treatment of DASS that we have termed revision using distal inflow (RUDI). Briefly, the technique involves ligation of the fistula at its origin followed by reestablishment of the fistula via bypass from a more distal arterial source to the venous limb. Four patients with brachial artery-based arteriovenous fistula and DASS underwent RUDI as described above using either the proximal radial or ulnar artery as inflow and vein as conduit. Patients were diagnosed with DASS based on the clinical findings of pain, pallor, loss of radial pulse, and sensorimotor dysfunction after creation of an AVF. Noninvasive vascular studies confirmed diminished finger pressures that improved with compression of the fistula. All patients experienced rapid resolution of their symptoms, although one patient complained of mild residual parasthesias. Follow-up ranging from 4 to 14 months has revealed patent functional fistulas. These initial results demonstrate that RUDI can be an effective treatment of DASS. By design, RUDI incorporates many of the advantages of established access-preserving procedures. That is, by using a smaller distal artery as inflow, RUDI lengthens the fistula, decreases the radius, and preserves antegrade flow in the brachial artery. In contrast to DRIL, it is the fistula, not the native arterial supply, that is placed at risk by ligation and revascularization. Consequently, we believe that RUDI may become the procedure of choice for DASS after brachial artery-based fistulas.