Onset of arterial 'steal' following proximal angioaccess: immediate and delayed types

Abstract

Background: Critical hand ischaemia following angioaccess is a potentially devastating complication and timely surgical repair is necessary to prevent permanent sequelae. However, the duration of the post-operative surveillance needed to exclude its occurrence has not been determined.

Methods: A retrospective review conducted over a 10-year period revealed 28 patients with critical hand ischaemia following access and surgical repair. The initial access that resulted in the limb-threatening 'steal' included 10 autologous brachiocephalic arteriovenous (AV) fistulae and 18 AV bridge grafts. The two groups of patients, those with autologous AV fistulae and those with AV bridge grafts, were compared regarding the time elapsed from the initial access to the correction procedure, the systolic pressure index between the two forearms and the existence of tissue loss.

Results: There was a highly significant difference in the time elapsed from the creation of the initial access to the revision procedure among the two groups, the median time being 2 days in the AV graft group and 165 days in the autologous group (P < 0.00001). The method of treatment was the distal revascularization-interval ligation (DRIL) procedure in the majority of patients (23 of 28), with immediate relief of ischaemic symptoms in all and a mid-term 1 year patency of 69%.

Conclusions: Severe steal develops immediately following AV bridge grafting and patients should be closely monitored during the first 24 h; surveillance is not indicated beyond 1 month. In contrast, steal following formation of proximal autogenous fistulae may be either of immediate or of 'late' onset, months or years after the creation of the fistulae, and lifelong monthly surveillance is recommended. Close monitoring is also recommended after any subsequent surgical or interventional correcting procedure for all access types. DRIL is the procedure of choice in limb-threatening severe steal.