Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques

Abstract

This systematic review and meta-analysis examine preventive operative techniques in high-risk patients undergoing surgery for hemodialysis access to mitigate the risk of Dialysis Access-Associated Steal Syndrome (DASS). Chronic kidney disease often leads to end-stage renal disease (ESRD), necessitating dialysis. Successful vascular access is crucial for efficient dialysis, but complications, such as DASS, pose significant challenges. DASS redirects arterial blood flow, affecting populations undergoing arteriovenous access surgery. This study aims to assess preventive strategies, including distal revascularization with interval ligation (DRIL) and extension techniques. A systematic search of PubMed, Cochrane Library, EMBASE, and Web of Science until 2022 identified 11 relevant studies. The inclusion criteria comprised non-pediatric hemodialysis patients reporting outcomes related to patency and complications. The data were analyzed using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Meta-analysis indicated a significant association between DASS and arteriovenous fistula (AVF) or arteriovenous graft (AVG) procedures. Radiocephalic AVF (RC-AVF) and distal endovascular AVF procedures were favored. Various interventions addressed venous narrowing, including simple plication and loop interposition. The Modified by Inserted Latex Link for Endovascular Repair (MILLER) technique, DRIL, Extension Technique, and Proximalization of Arterial Inflow (PAI) were assessed for arterial bypass graft and blood supply preservation. This study underscores the importance of individualized strategies in preventing DASS during hemodialysis access surgery. Prophylactic measures, such as the extension technique, show promise, while DRIL remains effective in treatment. Ongoing research is imperative for optimizing outcomes in this complex patient population.

Keywords: arteriovenous fistula; arteriovenous graft; end-stage renal disease; hemodialysis; steal syndrome; systematic review.

Figure 1. PRISMA 2020 flow diagram

Figure 2. Funnel plot illustrating the 24-month primary patency rates

Figure 3. Summary of risk of bias assessment

Ryu et al. [7], Mordhorst et al. [8], Kim et al. [9], Burnett et al. [10], Lee et al. [11], Carnevale et al. [12], Alsaadi [13], Parikh et al. [14], Mousavi et al. [15], Papadoulas et al. [16], and Alqassieh et al. [17].

Figure 4. Forest plot depicting the association between steal syndrome and hemodialysis vascular outcomes

The studies included in this analysis are as follows: Ryu et al. [7], Mordhorst et al. [8], Kim et al. [9], Burnett et al. [10], Lee et al. [11], Carnevale et al. [12], Alsaadi [13], Parikh et al. [14], Mousavi et al. [15], Papadoulas et al. [16], and Alqassieh et al. [17].