Referring Patients For Vascular Access Steal Syndrome

I recently saw a patient with diabetes at the wound care center for his foot ulceration. I see this patient on a weekly basis for care. At this appointment, he said he had noticed a dark spot on his right finger two days prior to the office visit. He was already scheduled to see the vascular surgeon after visiting my office.

I contacted the vascular surgeon and asked if she could take a look. The first question she asked is, “Is it on the same side as his dialysis access?” I affirmed it was. She responded that the condition sounded like vascular access steal syndrome. I recalled learning about this in podiatry school but I realized I needed to review this condition.     

Vascular access steal syndrome or dialysis-associated steal syndrome (DASS) is a clinical condition caused by arterial insufficiency distal to a hemodialysis site, an arteriovenous fistula or a graft due to diversion of blood into the fistula or graft.¹ Associated with reversal of distal flow without adequate collateral circulation, vascular access steal syndrome can progress to irreversible neuropathy, loss of function, gangrene, digit loss or limb loss.

The signs and symptoms of vascular access steal syndrome include:^2,3

• Pale, cold hand
• Diminished pulses (distal to the fistula)
• Necrosis
• Decreased wrist brachial index, especially if it is below 0.6
• Weakness
• Poor capillary filling

The most common treatment options are sacrifice of dialysis access (for severe ischemia), distal revascularization and interval ligation, and banding for access flow reduction.

References

1. Malik J, Tuka V, Kasalova Z, et al. Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies. J Vasc Access. 2008;9(3):155-66.

2. Porcellini M, Selvetella L, De Rosa P, et al. Hand ischemia due to "steal syndrome" in vascular access for hemodialysis. G Chir. 1997; 18(1–2):27–30.

3. Shemesh D, Mabjeesh NJ, Abramowitz HB. Management of dialysis access-associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction. J Vasc Surg. 1999; 30(1):193–5.

4. Spergel L. Management of steal syndrome. Fistula First, the National Vascular Access Improvement Initiative. Available at https://pedsmedia.ouhsc.edu/Fistula11/ .

5. Berman SS. Understanding steal syndrome: causes and prevention. Endovascular Today. 2009; 3:70-72. Available at https://evtoday.com/pdfs/EVT0209_10.pdf .