CASE REPORT
D ist a l r e va scu la r iza t ion a n d in t e r va l liga t ion for t h e t r e a t m e n t of st e a l
syn dr om e se con da r y t o h e m odia lysis a r t e r iove n ou s fist u la in t h e low e r
lim b
Ra fa e l D e m a r ch i M a lgorI; Rica r do de Alva r e n ga Yosh idaI I; M a r con e Lim a Sobr e ir aI I I; M a r iâ n ge la Gia n n in iI V; W in st on Bon e t t i Yosh idaV; H a m ilt on Alm e ida RolloV I
IFellow , Vascular Surgery Ser vice, Faculdade de Medicina de Bot ucat u ( FMB) , Univer sidade
Est adual Paulist a ( UNESP) , Bot ucat u, SP, Br azil.
I IGraduat e physician, Vascular Surgery, FMB, UNESP, Bot ucat u, SP, Brazil. I I IHired physician, Vascular Surgery, FMB, UNESP, Bot ucat u, SP, Brazil. I VAssist ant pr ofessor , Vascular Surgery, FMB, UNESP, Bot ucat u, SP, Brazil. VAssist ant pr ofessor , Vascular Surgery, FMB, UNESP, Bot ucat u, SP, Brazil. VIAssist ant pr ofessor , Vascular Surgery, FMB, UNESP, Bot ucat u, SP, Brazil.
Correspondence
J Vasc Bras. 2007; 6( 3) : 288- 92.
ABSTRACT
Art eriovenous fist ula w it h adequat e blood flow is ext r em ely im por t ant for pat ient s w it h chronic renal insufficiency undergoing hem odialysis. St eal syndrom e is a com plicat ion of ar t er iovenous fist ula, but it is r ar e and it s t r eat m ent is direct ly indicat ed w hen t here ar e associat ed sym pt om s. Alt hough m any t reat m ent s have been pr oposed for it s r epair in t he upper lim bs, dist al
revascularizat ion and int er val ligat ion is cur r ent ly t he t reat m ent of choice. This original case r epor t describes t he t r eat m ent of st eal syndrom e secondar y t o art eriovenous fist ula in t he low er lim b, w hich w as successfully t reat ed using t he sam e pr ocedur e descr ibed for t he upper lim bs.
Ke yw or ds:Art eriovenous fist ula, hem odialysis, st eal syndr om e, t herapeut ic approach.
RESUM O
t rat am ent o est á dir et am ent e indicado quando há sint om as m anifest os. Vários m ét odos foram propost os para sua cor r eção nos m em br os super ior es, sendo considerada a r evascular ização dist al com ligadur a ar t er ial o pr ocedim ent o de escolha. Nest e relat o de caso inédit o, descr eve- se o t rat am ent o da síndr om e do r oubo de um a físt ula ar t er iovenosa r ealizada em m em br o infer ior , t rat ada com sucesso por m eio da m esm a t écnica indicada para os m em br os superiores.
Pa la vr a s- ch a ve : Físt ula art eriovenosa, hem odiálise, síndr om e do roubo, t erapêut ica.
I n t r odu ct ion
Chr onic r enal failure ( CRF) is a disease t hat has a st rong socioeconom ic im pact on healt h car e of pat ient s w ho depend on t he public and/ or pr ivat e healt h syst em in Br azil. I t is est im at ed t hat appr oxim at ely 60,000 pat ient s w it h CRF are t r eat ed by dialyt ic m et hods and, of t hese, 89.6% by hem odialysis.1 Hem odialysis accesses defined as definit ive ar e sur gical pr ocedur es charact erized by com m unicat ion of a vein w it h an ar t er y, called ar t er iovenous fist ulas ( AVF) . Most of t hem ar e perform ed in t he upper lim bs and, except ionally, in t he low er lim bs. I n t his cont ext , AVF of choice is perform ed by dir ect anast om osis bet w een t he cephalic vein and t he radial art ery and, less frequent ly, by vascular graft s.2
According t o cur r ent consensus r epor t s, it is believed t hat const r uct ion of AVF bet w een t he radial art ery and t he dist al cephalic vein ( Br escia- Cim ino AVF) should be used as t he first t echnical opt ion, due t o t heir higher long- t erm pat ency, leaving synt het ic graft s for a secondar y alt ernat ive.2 , 3
St eal syndr om e associat ed w it h AVF is a relat ively rare, but pot ent ially severe clinical ent it y, w hose et iopat hogeny is due t o low er dist al blood supply, r esult ing fr om deviat ion of ar t er ial blood t hat is direct ed t o AVF and usually m anifest ed by lim b cooling, pain, pallor , m uscle fat igue and reduct ion or absence of dist al pulses.4 I t s diagnosis is em inent ly clinical, but can be confir m ed by noninvasive vascular m et hods, such as pr essur e index, digit al phot oplet hysm ography and/ or duplex scan, as w ell as by art eriography. I t s pr evalence is est im at ed in ar ound 1- 8% in upper lim bs;5 , 6 how ever , we found no pr evalence in low er lim bs in t he dat abases.5
Am ong t he varied t y pes of sur gical t r eat m ent for st eal syndrom e secondar y t o AVF, dist al
revascularizat ion and int er val ligat ion ( DRI L) offer s good out com es in upper lim bs.7 How ever , w e did not find any published report on r epair of st eal syndr om e using t his t echnique in low er lim bs in surveyed sour ces ( MEDLI NE, LI LACS, SciELO, EMBASE) from 1996 t o 2007, using t he t erm s art eriovenous fist ula, dialysis access, hem odialysis, st eal syndr om e, low er lim bs.
Ca se r e por t
A 56- year - old fem ale pat ient , hyper t ensive, w it h hypot hyr oidism and CRF undergoing hem odialysis and a st raight and synt het ic AVF in t he r ight low er lim b bet w een t he super ficial fem or al art ery and t he ar ch of t he great saphenous vein const ruct ed using a w ired expanded polyt et rafluoroet hylene ( PTFE)® vascular gr aft m easur ing 8 m m in diam et er .
syndrom e, char act er ized by reduct ion in lim b t em perat ure and per fusion, pain on palpat ion of calf m uscle, disappear ance of poplit eal and t ibial pulses, besides reduct ion in ankle- brachial index ( ABI ) at rest from 1.0 t o 0.3. The pat ient w as subm it t ed t o a t readm ill t est ( Gar dner pr ot ocol) , w it h pr esence of claudicat ion for m ore t han 500 m ; w e t hen chose t o per for m conser vat ive t reat m ent based on physical exer cises ( w alking) and clinical follow- up.6
How ever, sym pt om s w er e int ensified aft er t he first hem odialysis session, perform ed 25 days aft er t he sur ger y, m anifest ed by pain at r est , w orsening of pallor and lim b cooling, com pat ible w it h crit ical ischem ia. Despit e not having any change in ABI at r est , art erial scr eening w as perform ed using duplex scan, w hich show ed: pat ent com m on, superficial and deep fem oral art eries and w it h preserved hem odynam ic pat t er ns; pat ent poplit eal, fibular , ant er ior and post erior t ibial art eries, but w it h t w o- phase art erial cur ves and m aj or degenerat ion of hem odynam ic pat t erns of ar t er ial curves from t he dist al t hir d of t he t high, char act er ized by one- phase, low - speed ar t er ial curves ( Figure 1) .
The pat ient w as t hen subm it t ed t o sur gical t reat m ent using dist al revascularizat ion and int er val ligat ion, int er nat ionally know n as DRI L7 w hich had probably not been descr ibed for t he t r eat m ent of t his syndrom e in low er lim bs so far.
To do so, a by pass w as perform ed bet w een t he proxim al art ery ( super ficial fem oral ar t er y,
AVF present ed good pat t ern ( m ean pr essur e of 156 m m Hg and m ean flow of 300 m L/ second) .
D iscu ssion
The first descr ipt ion of t he st eal syndrom e associat ed w it h vascular accesses for dialysis was perform ed by St or ey et al. in 1969, secondary t o an AVF bet w een t he r adial art ery and t he dist al cephalic vein ( Br escia- Cim ino) .8 Alt hough rare, st eal syndrom e causes discom fort and im port ant sym pt om s, able t o r est r ict t he pat ient 's act ivit ies. Accor ding t o Schanzer & Skladany, severe ischem ia r elat ed t o st eal syndrom e occur s in about 1% of cases, especially w hen t he AVF is
const ruct ed bet w een t he brachial art ery and t he ant ecubit al vein, and in 2.7- 4.3% of pat ient s w it h bypass AVF.4
Berm an et al. show ed t hat only 0.3% of t heir pat ient s subm it t ed t o AVF of t he upper lim bs, w it h preoperat ive assessm ent alt ered by segm ent al Doppler or pr eoper at ive digit al Doppler , developed st eal syndrom e, concluding t hat t here was no need of perform ing com plem ent ar y r out ine
exam inat ions.9 I t s diagnosis is perform ed by t he associat ion of m anifest at ions com pat ible w it h low art erial supply t o t he AVF, such as lim b cooling, sensit ive loss, pallor and pain at r est ,7 associat ed w it h com plem ent ar y exam inat ions, usually noninvasive, such as pr essur e index,
phot oplet hysm ography or pneum oplet hysm ogr aphy,5 , 1 0 duplex scan 1 1 , 1 2 and, occasionally by
art eriography.1 3
So far t here ar e no m eans t o exact ly pr edict w hen t he st eal syndr om e w ill occur ,9 , 1 4 but several t echniques used for it s correct ion are descr ibed, w hich can be sum m ar ized in t hr ee t ypes:
- AVF ligat ion w it h r esolut ion of st eal syndr om e, but w it h loss of access.
- Access cer clage using banding int erposit ion, but w it h t he inconvenience of increasing dist al resist ance, w hich causes r educt ion in blood flow and incr ease in chance of t hr om bosis in t he AVF.1 5 To m inim ize blood flow r educt ion in t his t echnique, Aschw anden et al.1 6 proposed perioperat ive assessm ent using duplex scan dur ing cer clage, r ecom m ending t hat dist al art erial pr essur e and digit al- brachial index should be higher t han 60 m m Hg and 0.5, r espect ively, at t he end of t he pr ocedur e.
- Dist al r evascular izat ion and int er val ligat ion ( DRI L) , pr oposed by Schanzer et al.1 7 Good long- t erm pat ency out com es and pat ient 's clinical im pr ovem ent1 8 - 2 0 w er e exclusively r epor t ed in t he upper lim bs.7 , 9 , 1 7
As pr eviously st at ed, const r uct ion of AVF in t he low er lim b is not fr equent , being an except ion choice, perform ed in cases in w hich t here was exhaust ion of accesses in t he upper lim bs.2 1 I n our inst it ut ion, less t han 5% of pat ient s have AVF in t he low er lim bs, and in t his report , w e not iced t hat st eal syndrom e, sim ilar ly t o what occurs in t he upper lim bs, can pot ent ially occur in t he low er lim bs, despit e absence of any descr ipt ion in t he sur veyed lit er at ur e.
I n preoperat ive assessm ent , t he pat ient did not report any com plaint of int er m it t ent claudicat ion and had ant erior and post erior poplit eal and t ibial pulses, w hich suggest s she did not have
peripheral art erial disease ( PAD) , even having CRF. How ever , perform ing a t r eadm ill t est w it h ABI before const r uct ing t he AVF could have assessed m or e pr ecisely pr esence or not of PAD.
higher prevalence of PAD in the lower limbs associated with risk factors prevalent in this population, we believe that further studies are necessary to construct AVF in the lower limbs.
Con clu sion s
Based on this report, we can infer that:
-Steal syndrome secondary to an AVF can also occur in the lower limbs;
-The DRIL technique, despite being described for the treatment of steal syndrome secondary to an AVF only in the upper limbs, proved to be a good therapeutic option for the same problem in the lower limb.
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Cor r e spon de n ce :
Rafael Demarchi Malgor
Departamento de Cirurgia e Ortopedia Universidade Estadual Paulista
Rua Rubi€o J‹nior, s/nŒ
CEP 18618-000 – Botucatu, SP, Brazil
Email: [email protected]
