1. M Mazen Hachem*, MD, PhD, FACS., M Bosaeed* and M Wakka* *Division of Vascular Surgery King Abdul-Aziz Medical City Jeddah, KSA Upper Limb Ischemia After Vascular Access Surgery Differential Diagnosis and Management

3. Ischemic Complications of VA Ischemic Steal Syndrome (ISS) & Ischemic Monomelic Neuropathy (IMN) are devastating complications of VA procedure and mostly are subject to malpractice & lawsuit 90% have steal phenomena – 5-20% have ischemic steal syndrome – 0.5-1% have IMN Duncan et al., JVS 4: 144, 1986 Odland et al., Surgery 110:664, 1991

4. Ischemic Complications of VA Ischemic Steal Syndrome ISS results from uncompensated steal phenomena Regardless of VA flow – Poor collaterals – Proximal arterial stenosis Reversible if treated promptly

5. Ischemic Complications of VA Ischemic Monomelic Neuropathy IMN results from blood flow alteration to vasa nervosum of Median, Radial & Ulnar nerves producing claw hand. Regardless of VA flow. – Irreversible even with appropriate strategy and early intervention. Absence of severe tissue ischemia differentiate IMN from ISS.

6. Objectives 1.Recognize clinical presentations – Ischemic Steal Syndrome – Ischemic Monomelic Neuropathy 2.Be familiar with treatment options 3.Select appropriate treatment options for each case.

7. Ischemic Steal Syndrome Ischemic Monomelic Neuropathy Predominant featureCold hand with pain on or off dialysis Weakness and paralysis of muscles with prominent sensory loss OnsetAcute and chronicImmediately Access typeCommon with upper arm but also seen with forearm accesses Only in proximal access SexVariableFemale>Male Tissue involvedSkin > muscle > nerveNerves CauseVascular insufficiency leading to distal hypoperfusion Vascular insufficiency causing nerve damage Radial pulseUsually diminished or absentUsually present Diagnostic evaluationHistory,/ physical examination, and arteriography History and the clinical features More prevalent in Patients with diabetes, peripheral vascular disease, smokers Patients with diabetes, peripheral vascular Disease + PN Management strategies Percutaneous and or Surgery Access ligation?????

8. Ischemic Steal Syndrome Diagnosis History/ Physical examination – Coldness – Radial pulse W/O access occlusion – Motor weakness & Sensory deficit – Trophic changes (late SS).

9. Ischemic Steal Syndrome Diagnosis Vascular Lab – Significant reduction in digital pressure and pulse volume recording – Digital pressure and pulse volume improve Occlusion of AVF Occlusion of V outflow Occlusion of RA distal to AVF – Digital pressure and pulse volume made worse Occlusion of RA proximal to AVF Occlusion of UA Angiogram

10. Grading of Ischemic Steal Syndrome GradeSymptomsManagement 0 AsymptomaticNothing I Cold hand with tolerable symptoms Flow augmentation by access occlusion Observation II Ischemic symptoms during dialysis “Claudication” Non-Invasive Study Medical + Angiogram PTA/ Surgery III Rest pain / Tissue lossAngiogram & proceed

11. Ischemic Steal Syndrome Goals of Treatment Restore perfusion to the hand Maintain Vascular Access

12. Ischemic Steal Syndrome Treatment Options Do nothing PTA Surgery 1.Access ligation 2.Banding 3.Distal Revascularization-Interval Ligation (DRIL) 4.Distalizaion of arterial inflow (RUDI) 5.Proximalization of arterial inflow (RUPI) 6.Minimally Invasive Limited Ligation Endoluminal- Assisted Revision (MILLER)

13. Treatment Options Restore perfusion Lost Vascular Access “Blind” banding w/o consideration of access flow is ineffective and ill-advised. Access Ligation Banding

14. Treatment Options Bypass increase distal flow Eliminate steal phenomena due to arterial ligation Resolved ischemia – Distal flow depending bypass What’s a DRIL Procedure? Procedure Schanzer H, Schwartz M, Harrington E, Haimov M: Treatment of ischemia due to “steal” by arteriovenous fistula with distal artery ligation and revascularization. J Vasc Surg 7: 770–773, 1988

15. mmhachem 2006-2007 Brachial artery Brachial-to-brachial bypass Cephalic vein Anastomosis site Interval ligation

16. Treatment Options Increase distal flow Decrease steal phenomena Distal ischemia resolved Minion DJ, Moore E, Endean E: Revision using distal inflow: A novel approach to dialysis-associated steal syndrome. Ann Vasc Surg 19: 625–628, 2005 RUDI Procedure

17. Treatment Options Increase distal flow Eliminate steal phenomena due to high graft resistant Resolved ischemia RUPI Procedure J Zanow, U Kruger, H Schlz: Proximalization of arterial inflow: A new technique to treat access-related ischemia; J Vasc Surg, 43:1216-1221, 2006

18. Treatment Option Minimally Invasive Limited Ligation Endoluminal assisted Revision Gregg A. Miller, MD. 2006 What’s a MILLER Outpatient Procedure

19. MILLER Procedure

20. ACCESS FLOW MEASURMENT Treatment Options Guideline

21. Treatment Options Guideline Measurement Access Blood Flow Access blood flow will dictate management option: – Low or normal access flow DRIL – High access flow MILLER or RUDI or RUPI

22. RESULTS

23. AuthorsYear Proc. No. Pt.Results De Caprio1997 Banding 18100% ischemia resolved 1/11 AVG patent at 6 m 0/7 AVF patent at 30 D Haimovici1996 DRIL 34100% ischemia resolved 73% AVG patency at 1 year 96% bypass patency at 1 year Hachem2006 DRIL 1690% ischemia resolved 87.5% VA patency at1 year 81% bypass patency at 1year Zanow2006 RUPI 3080% ischemia resolved 90% patency MILLER2010 MILLER 11496% ischemia resolved 90% patency at 1 year Minion2005 RUDI 6 100% ischemia resolved 100% patency 14m Minion2005 RUPI 4 100% ischemia resolved 100% patency at 1 year

24. Conclusion Pay special attention to the elderly diabetic females with neuropathy – Immediate evaluation if post-op hand pain or other evidence of significant ischemia Diagnosis almost can be made on clinical features & non-invasive studies Angiogram is mandatory Proximal arterial stenosis is a common contributing factor to hand ischemia

25. Conclusion Surgical treatment should provide – Adequate access flow – Restoring adequate flow to the extremity. Main treatment options for ischemic steal syndrome – MILLER procedure – RUDI – RUPI – DRIL Challenge is there for IMN