Creation of a Transposed Mature Arteriovenous Fistula Autograft: A Novel Approach to Treating Steal Syndrome

Abstract

Background: Autogenous arteriovenous fistula (AVF) creation is the gold standard of hemodialysis access. However, autologous upper extremity AVFs continue to present significant clinical challenges including failure to mature and steal syndrome. We describe treating a patient with dialysis-associated steal syndrome (DASS) by ligating and then transposing a well-developed, mature upper arm cephalic vein AVF into the contralateral arm.

Methods: Our patient is a 76-year-old female with end-stage renal disease (ESRD) secondary to glomerulonephritis, who had a left arm brachiocephalic AVF created in 2007. She developed DASS in 2013, presenting with hand pain and ulcerations on her fingertips. A right brachial-cephalic AVF was created with plans of ligating the left AVF once mature. The right arm AVF did not mature so we created an arteriovenous graft (AVG) in the right arm utilizing the mature left arm cephalic vein as an autograft.

Results: The autograft was transposed and implanted in the right upper arm. The translocated AVF worked for 4 years and was eventually ligated due to right hand ischemia secondary to progression of small vessel peripheral arterial disease.

Conclusions: Transposition of autogenous vein grafts using a mature AVF is a viable option for dialysis access in ESRD patients. We report successful utilization of this novel access option in the treatment of a patient with DASS. The mature autograft retains the natural matrix and endothelial lining and thus may potentially prove to offer improved patency and reduced infection rate compared to other available AVG options.