Show Notes
Guest: Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine. He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic.
Resources: Rutherford Chapters (10th ed.): 174, 175, 177, 178
Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/
The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext
KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/
Outline: Steal Syndrome
Definition & Etiology
Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand.
Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow.
Incidence and Risk Factors
The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice
Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits.
Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4
Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries' ability to vasodilate and adjust to decreased blood flow.
Patient Presentation, Symptoms, Grading
Steal syndrome is diagnosed clinically.
Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation.
Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of symptoms that can take months or years.
The patient should have a unilateral complaint in the extremity with the AV access. Symptoms of steal syndrome, in order of increasing severity, include nail changes, occasional tingling, extremity coolness, numbness in fingertips and hands, muscle weakness, rest pain, sensory and motor deficits, fingertip ulcerations, and tissue loss.
There could be a weakened radial pulse or weak Doppler signal on the affected side, and these will become stronger after compression of the AV outflow.
Symptoms are graded on a scale specified by Society of Vascular Surgery (SVS) reporting standards:5
Workup
Duplex ultrasound can be used to analyze flow volumes.
A high flow volume (in autogenous accesses greater than 800 mL/min, in nonautogenous accesses greater than 1200 mL/min) signifies an outflow issue. The vein or graft is acting as a pressure sink and stealing blood from the distal artery. A low flow volume signifies an inflow issue, meaning that there is a proximal arterial lesion preventing blood from reaching the distal artery.
Upper extremity angiogram can identify proximal arterial lesions.
Prevention
Create the AV access as distal as possible, in order to preserve arterial inflow to the hand and reduce the anastomosis size and outflow diameter.
SVS guidelines recommend a 4-6mm arteriotomy diameter to balance the need for sufficient access flow with the risk of steal.
If a graft is necessary, tapered prosthetic grafts are sometimes used in patients with steal risk factors
More from Audible Bleeding
Audible Bleeding editor Wen Kawaji (@WenKawaji) is joined by Dr. Danielle Garcia, Dr. Robert Meyers, JVS editor Dr. Duncan (@ADuncanVasc), and JVS-VL editor Dr. Ruth Bush to discuss some of our favorite articles in the JVS family of journals.
Jacob Soucy (@JacobWSoucy) hosts an inside look at a timely and thought-provoking editorial published in The Vascular Specialist, the official news magazine of the Society for Vascular Surgery. In this episode, we explore the introduction of preference signaling to the integrated vascular surgery match through the lens of the editorial "This Signal Brings Noise." The discussion examines whether signaling addresses problems that exist within the vascular surgery match, how signals may influence interview selection, and the potential unintended consequences of introducing artificial scarcity into an already highly successful match process. Jacob speaks with Dr. Malachi G. Sheahan III about the motivation behind the piece, the problems preference signaling is intended to solve, how applicants and programs may approach the new system, and why signaling may turn the application process into a strategic game. They also discuss application review, virtual versus in-person interviews, the role of program reputation and mentorship in applicant decision-making, and what the vascular surgery community should watch as signaling is implemented for the first time.
Audible Bleeding Editor and vascular surgery fellow Sasank Kalipatnapu (@ksasank) is joined by James Martinson, a practicing general surgeon with an interest in vascular surgery, currently serving as the ship's surgeon for the USS John F. Kennedy aircraft carrier; JVS editor Dr. Audra Duncan (@ADuncanVasc); and JVS-CIT editor Dr. Matthew Smeds (@MattSmeds) to discuss two great articles in the JVS family of journals. Articles: Part 1: The association between multimorbidity and arteriovenous fistula creation outcomes (Wei and Woo)
Audible Bleeding Editor and vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by James Martinson, practicing general surgeon with an interest in vascular surgery currently serving as the ship's surgeon for the USS Harry S Truman aircraft carrier and Langford Green (@langfordgreen_), research fellow at the Center for Vascular Research at the University of Maryland currently applying to medical school, JVS editor Dr. Audra Duncan (@ADuncanVasc), and JVS-VI editor Dr. Anahita Dua (@AnahitaDua) to discuss two great articles in the JVS family of journals. Articles: Part 1: Open bypass versus endovascular therapy in chronic limb-threatening ischemia patients with prior endovascular attempts (Hamouda & Malas)
Welcome back to the Audible Bleeding Series: Landmark Papers in Vascular Surgery. In this episode, Audible Bleeding editor John Culhane and co-host Dr. Jesse Columbo are joined by our guests, Dr. David Stone, Dr. Salvatore Scali, and Dr. Anders Wanhainen to unpack one of the longest-running debates in aortic surgery: when (and whether) to repair an abdominal aortic aneurysm. We'll start our episode with the open-repair era and the two trials that set the basis for the 5.5 cm threshold—UKSAT and ADAM—then move into the early EVAR years with PIVOTAL and CAESAR, which asked whether fixing smaller aneurysms with endovascular technology could do better. Finally, we'll look at how modern screening programs, improved medical therapy, and current guidelines have reshaped the practical decisions we make for these patients every day.