Objectives: Clinical findings in dialysis access steal syndrome (DASS) include asymptomatic flow reversal, hand ischemia and tissue loss. Treatment options include proximalization of the arterial inflow (PAI) and banding, both of which have been established as acceptable alternatives to distal revascularization with interval ligation (DRIL). We directly compared outcomes among patients undergoing PAI and banding for symptomatic DASS.
Methods: This is a single institution retrospective cohort study. We collected demographic, comorbid perioperative, hemodynamic and postoperative data on all patients undergoing hemodialysis revision for grade 3 and 4 DASS from 2016 through 2021. Symptomatic improvement and patency at 6 and 12 months were assessed.
Results: Forty-six patients underwent 50 procedures. Twenty-five patients underwent PAI (50%) and 25 (50%) underwent banding. The mean age was 60.3 years and 68% were female. No patients were treated with DRIL or revascularization using distal inflow in the study period. Comorbidities included diabetes (74%), hypertension (98%), CAD (64%), PAD (32%) and hyperlipidemia (70%). Demographics were similar in both groups. Seventy percent of patients had grade 3 and the remaining 30% had grade 4 DASS. In the PAI cohort, 100% of the original access was brachial artery based, compared to 76% in the banding cohort. Grafts were used for access in 48% in the PAI compared to only 4% in the banding group. Severity of symptoms was also similar between groups with 68% of PAI patients having grade 3 and 32% having grade 4 DASS. Among banding patients 72% had grade 3 and 28% had grade 4 DASS. The PAI group had a mean access age of 22 months compared to patients undergoing banding with a mean age of 29 months. Patients undergoing PAI had a mean preop volume flow (VF) of 1151ml/min compared to the higher volume flow seen in patients undergoing banding where the VF was 2070ml/min. Postop VF was similar between PAI and banding groups at 1089ml/min vs 931ml/min. Patients managed with PAI experienced symptomatic improvement in 68% of cases compared to 36% among banding patients. Patency at 6 and 12 months was higher in the banding group at, 75% and 70% compared to 68% and 54% for PAI.
Conclusions: Banding and PAI are acceptable methods of treating DASS. Patients with low flow DASS typically were revised with PAI while patients with high flow DASS usually underwent banding. Symptomatic improvement is superior with PAI, however banding is associated with a slightly higher rate of access preservation.
