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Endovascular Treatment for Access Induced Steal Syndrome Using Flared Stent
Chien Yi M. Png, William E. Beckerman, Rami O. Tadros, Reid A. Ravin, Peter L. Faries, Michael L. Marin, David J. Finlay.
Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objective(s):
Access-induced steal syndrome is a relatively uncommon but dreaded complication seen in patients with dialysis access grafts or fistulas. Several surgical procedures have been developed to treat steal syndrome. However, of the two most popular treatments, banding is associated with high rates of thrombosis and distal revascularization interval ligation (DRIL) is complex and time consuming.
Methods:
We present three cases of access-induced steal syndrome—each treated purely endovascularly. Post-anesthesia, intra-operative ultrasound was used to map and access the fistula/graft. A fistulogram was obtained through a 4Fr catheter introduced into a 6Fr short sheath. A 9Fr Bard Flair flared endovascular stent graft was then inserted bareback (post sheath-removal) and deployed just beyond the arterial anastomosis. By being confined to a straight conduit, the flared portion of the stent graft created a natural uniform narrowing of the fistula/graft. Pulse oximetry and a repeat fistulogram were used to monitor brachial artery outflow improvement, and if indicated, an additional flared stent graft was placed to overlap the first.
Results:
Two of the three patients required two flared stents to achieve desired distal flow. All three patients had spontaneous resolution of their steal syndrome, with marked improvements in digital pulse oximetry. Mean follow-up was 4 months. One patient developed ulnar pain/contractions at one year post-op unrelated to any vascular etiology.
Conclusions:
This small case series suggests that our purely endovascular approach is viable in patients who are suboptimal candidates for open surgery. As it spares patients the need for an invasive procedure and reduces operating time, we propose continued usage of flared covered stents in a select group of access-induced steal syndrome patients who are at high surgical risk.


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