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Upper Extremity Endovascular Interventions for Symptomatic Vascular Access-induced Steal Syndrome
Tracy Cheun, MD, Taylor D. Hicks, MD, Georges M. Haidar, MD, Lori L. Pounds, MD, Matthew J. Sideman, MD, Mark G. Davies, MD PhD MBA.
UT Health, San Antonio, TX, USA.

Objectives: Critical hand ischemia due to vascular access-induced steal syndrome continues (VASS) to be a significant problem. The aim of this study was to examine the outcomes of endovascular interventions in the upper extremity of patients presenting with VASS.
Methods: A database of patients presenting with documented VASS between 2006 and 2016 was retrospectively queried. Patients who underwent isolated endovascular intervention in the upper extremity were analyzed.
Results: 98 patients (66% female, average age 65 years) presented with VASS: 28 presented with upper arm atherosclerotic disease and the remainder with below elbow atherosclerotic disease. 93% presented with rest pain and the remainder with minor digital ulceration. 76% of the patients had arterio-venous fistulas (majority with a brachial artery origin) and the remainder had upper arm prosthetic AV grafts. Of those with upper arm disease, 1/3 of the patients had subclavian occlusive disease and 2/3 had brachial artery occlusive disease. Patients with subclavian disease underwent stent placement and patients with brachial artery disease underwent balloon angioplasty. Technical success was 100%. 91% of the patients had symptomatic success at 30 days and the remainder required access proximalization. Of those with below elbow disease, all had disease in the forearm vessels with 42% having either the ulnar or radial artery occlusion. Balloon angioplasty was performed in 1 vessel in 55% and in 2 vessels in 45% of the patients. Technical success was 79% with 51% of the patients having symptomatic success at 30 days; of those who remained symptomatic 76% required proximalization of the access and 24% required ligation. The MACE rate was 4%. The 30-day mortality rate was 0% and the morbidity rate was 7%. At 5 years, cumulative patency was 719% and 418% for the upper arm and forearm interventions respectively. The 5-year freedom from re-intervention was 929% and the 5-year freedom from recurrent VASS was 938%. The predictors of endovascular success were one vessel forearm runoff, an intact palmar arch and presence of digital run-off.
Conclusions: Upper extremity interventions for VASS are associated with a high rate of success (62%) with no mortality and a low morbidity. In correctly selected patients, endovascular interventions of the upper and forearm vessel have a role in the management of VASS.


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