Inflow stenosis as a contributing factor in the etiology of AV access-induced ischemic steal

Objective: To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). Methods: A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, preoperative angiographic imaging and interventions performed were analyzed. Results: A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1). Conclusion: In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete preoperative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.