In patients on hemodialysis using arteriovenous (AV) access on the ipsilateral side, hand ischemia is recognized as steal syndrome. In addition, peripheral arterial disease (PAD) is often seen in patients with end-stage renal disease (ESRD). In this patient population, there is an association between the presence of both PAD and steal syndrome and significant mortality. Online at the NKF Spring Clinical Meetings, Jenna Alkhatib, MD, and colleagues presented a case of a dialysis patients with known history of PAD who presented with ischemic hand distal to the ipsilateral dialysis access.
The African American patient is 53 years of age with a history of hypertension, HIV, PAD, and ESRD. He has been on hemodialysis via a left upper arm AV fistula since 2003. He presented with a left index finger non-healing non-traumatic ulcer and left arm pain during dialysis for the last few weeks.
The physical exam was remarkable for left upper arm AV fistula with large aneurysmal formations and weak left radial pulse, absent bilateral distal pedal dorsalis pulse and left second toe amputation. The findings raised the suspicion for steal syndrome.
The patient underwent fistulogram and arteriogram of the left upper extremity that showed large aneurysmal formations of the fistula body and severe arterial calcification. The arteriogram without occluding the AV fistula showed an excellent flow to the AV fistula and a minimal flow into the left radial and ulnar arteries. Fistula occlusion markedly improved the arterial flow, confirming the steal syndrome diagnosis. The patient was referred to vascular surgery for banding procedure and aneurysmal repair.
“Our case showed the ESRD with large AV fistula can cause the shunting of blood into the venous circulation away from the distal extremity. The compromised blood flow to the distal extremity is exacerbated by the presence of PAD. This case highlights the challenges encountered in managing dialysis patients with concomitant PAD and steal syndrome,” the authors said.
Source: Alkhatib A, Hamwyeh B, Al-Balas A, Almehmi A. Concomitant steal syndrome and peripheral arterial disease in a dialysis patient. Abstract of a presentation at the National Kidney Foundation 2020 Spring Clinical Meetings, abstract #301.