Vascular Medicine 2009; 14: 371376

Ischemic steal syndrome following arm arteriovenous fistula for

hemodialysis
Payman Zamani Cardiovascular Division, Veterans Affairs Boston Healthcare System and Cardiovascular
Division, Brigham and Womens Hospital and Harvard Medical School, James Kaufman Renal Division,
Veterans Affairs Boston Healthcare System and Boston University School of Medicine and Scott Kinlay
Cardiovascular Division, Veterans Affairs Boston Healthcare System and Cardiovascular Division,
Brigham and Womens Hospital and Harvard Medical School

Abstract: Arteriovenous fistulae in the arm are commonly used for hemodialysis in
end-stage renal disease. Although physiological steal with reverse flow in the artery
distal to the fistula is common, hand ischemia or infarction are rare. The ischemic
steal syndrome (hand or forearm ischemia) is usually a result of arterial disease prox-
imal or distal to the fistula and/or poor collateral supply to the hand. The diagnosis is
primarily clinical; however, markedly reduced digital pressures and pulse volume
recordings support the diagnosis. Management requires imaging for focal stenoses
or disease in arteries proximal and distal to the fistula from the aorta to the hand. We
present a case caused by subclavian artery occlusion that was initially missed due to
focusing investigation only on the fistula. We describe the percutaneous treatments
and surgical revisions that attempt to restore flow to the hand without compromising
the fistula.

Keywords: angioplasty, fistula, gangrene, ischemia, peripheral vascular diseases,

subclavian artery, vascular fistula

Introduction
Arteriovenous fistulae in the arm are the preferred
access for hemodialysis in end-stage renal disease.
The most common complication of fistula is throm-
bosis. More rarely, hand ischemia or digital infarc-
tion occurs due to poor distal blood flow. All
fistulae shunt blood away from the distal arm, and
physiological steal (reversed flow in the artery distal
to the arteriovenous fistulae) can occur in 70% of
radiocephalic fistulae and 90% of brachial artery
fistulae.1 However, symptoms of hand ischemia
(pain, parasthesia, or gangrene) only occur in
12% of radiocephalic fistulae and 510% of bra-
chial artery fistulae.29 The following case highlights
the approach and pitfalls to managing the ischemic
steal syndrome associated with a fistula in the arm.
Corresponding author: Scott Kinlay, Director, Cardiac
Catheterization Laboratory and Vascular Medicine,
Cardiovascular Division, VA Boston Healthcare System, 1400
VFW Parkway, West Roxbury, MA 02132, USA.
E-mail: scott.kinlay@va.gov
Dr Robert Eberhardt was the Guest Editor for this manuscript.
Case
An 88-year-old man was admitted to the Boston VA
with a 5-month history of pain in the left arm and
hand and a 2-month history of progressive dry gan-
grene on the tips of the second and third fingers of
his left hand. He had end-stage renal disease due to
long-standing type II diabetes mellitus and hyper-
tension, and received hemodialysis from a left
upper arm brachial artery basilic vein transposition
fistula created 4 years earlier.
He had an extensive history of atherosclerotic
peripheral vascular disease including a right carotid
endarterectomy 11 years earlier, a right below knee
amputation 2 years earlier, and a left above knee
amputation 6 months prior to his hand symptoms.
At the time of his last amputation he had subopti-
mal blood flow rates with the fistula during dialysis,
and he had a left fistulogram that showed a moder-
ate stenosis at the arterial-venous anastomosis of his
fistula, which was treated by cutting balloon angio-
plasty. In the following weeks he developed pain in
his left hand and fingers during hemodialysis and
when moving his wheelchair. He developed a small
non-healing ulcer on his left index finger that pro-
gressed to gangrene on three digits of the hand. His
left arm and hand pain became continuous, and he

The Author(s), 2009. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/1358863X09102293

372 P Zamani et al.
had absent radial and ulnar pulses. He was evalu-
ated with an arch aortogram that showed a 45 mm
occlusion of the left subclavian artery (Figure 1A).
His operative risk for a subclavian bypass was con-
sidered too high due to his co-morbidities, and it
was initially thought an endovascular approach
would be unsuccessful due to the long occlusion.
After a second opinion, he was offered an endovas-
cular approach using equipment commonly used to
cross coronary artery occlusions.
In the Cardiac Catheterization Laboratory, the
left femoral artery was accessed and a 6-F LIMA
guide was used to cannulate the left subclavian
stump. The artery was crossed using a 0.014 6g
Asahi Miracle guidewire (Abbott Laboratories,
Abbott Park, IL, USA) (Figure 1B) and dilated with
1.5 9 mm and 2.5 15 mm 0.014 balloons. The
guide was exchanged for an 8-F LIMA guide and
the lesion stented with 9.0 mm balloon expandable
stents dilated to 10 mm (Figure 1C). Angiography
from the left subclavian artery distally demon-
strated a widely patent brachial artery, fistula, and
a patent radial artery to the wrist. Immediately fol-
lowing the procedure, the patient reported resolu-
tion of his pain and warmth in his left hand
(Figure 1D). He had hemodialysis from his fistula
with improved dialysis flow rates (400500 ml/
Figure 1 (A) Arch aortogram showing proximal occlusion of the left subclavian artery. (B) Selective angiogram show-
ing the occluded subclavian stump with a 0.014" wire crossing the occlusion. (C) Successful stenting of the proximal
subclavian artery. (D) Left hand showing digital gangrene with hyperemia after stenting the subclavian artery.
Vascular Medicine 2009; 14: 371376
min). The gangrene in his fingers remained stable
and did not require surgical intervention.
Pathophysiology of the ischemic steal
syndrome
Physiologic steal with reverse flow in the arm artery
distal to the fistula is common after the creation of a
fistula because of the low vascular resistance of the
fistula.7,10 This can be identified clinically by com-
paring the blood pressure distal to the fistula to a
more proximal blood pressure or one in the contra-
lateral forearm. For example, the systolic pressure
index is a comparison of the systolic pressure in the
forearm below the fistula using a hand-held Doppler
device versus the contra-lateral arm.7 In most cases,
particularly with upper arm fistulae, the index is
below 0.8 in the 24 hours after creating the fistula.
The index tends to increase in the months after crea-
tion of the fistula, most likely due to the development
of collateral arteries from the proximal inflow artery
that increases blood flow to the hand.7,10
Although steal is common, symptoms of ischemia
are rare and likely prevented by compensatory vaso-
dilation of the distal arm arteries and subsequent
increased collateral flow to the forearm and hand

to maintain adequate perfusion.10 Hand ischemia
may occur during hemodialysis because dialysis
tends to lower venous return, reducing cardiac out-
put and lowering the perfusion pressure in the fistula
outflow artery and collaterals that supply the
hand.10
Pathological steal with continuous ischemic
symptoms can occur because of proximal inflow dis-
ease, reduced collateral flow to the hand, or distal
outflow obstruction.11,12 These all disturb the nor-
mal compensatory mechanisms (peripheral vasodi-
lation and increased collateral flow) to preserve per-
fusion to the distal arm. Any vascular disease that
affects the proximal or distal arteries (e.g. athero-
sclerosis, vasculitis, Buergers disease) can reduce
flow to cause symptoms. Proximal inflow disease
can occur in 2030% of patients with ischemia of
the hand,2,8 as illustrated by our case of subclavian
artery occlusion.
Although end-stage renal disease is associated
with many atherosclerosis risk factors, the risk fac-
tors for ischemic steal syndrome include diabetes
mellitus, peripheral artery disease, age greater than
60 years, women, upper arm versus lower arm fistu-
lae, multiple operations in the same limb, and the
use of PTFE grafts.3,4,8,13,14 These factors presum-
ably relate to increased or more diffuse arterioscle-
rosis of the arteries in the forearm and hand, and
poor development of collaterals.
Assessment
Diagnosis of the ischemic steal syndrome
Since physiological steal is common, ischemic steal
syndrome is primarily a clinical diagnosis. Signs
include pallor, diminished or absent peripheral pulses
in the arm or hand, sensory or motor neuropathy,
and distal infarction or ulceration. The occurrence
of ischemic steal has been divided into early (less
than 30 days after fistula creation) or late (30 or
more days) presentations.7,14 Severe presentations
of critical limb ischemia with motor dysfunction
immediately after fistula creation usually need urgent
revision, revascularization, or ligation. Milder symp-
toms may resolve spontaneously, likely due to the
development of collaterals to the hand, whereas
later presentations are usually progressive.7,10
Several non-invasive physiological techniques
can assess pressure and flow distal to the fistula to
quantify the extent of steal. These techniques may
identify those at risk of developing the syndrome or
provide supportive evidence for the diagnosis in the
presence of clinical findings.
Physiological measures of distal limb perfusion
include digital plethysmography and pulse volume
recordings, the digital pressure index (ratio of digital
to brachial pressure), and the systolic pressure index
Vascular Medicine 2009; 14: 371376
Ischemic steal syndrome 373
(ratio of the fistula forearm to contralateral forearm
pressure). Digital pulse volume recordings in most
asymptomatic patients with healthy fistula show a
phasic waveform that is augmented by occluding
the venous limb of the fistula.10 However, in the
ischemic fistula syndrome, digital systolic pressures
are usually less than 50 mmHg and the resting digital
pulse volume recordings are flat but return to a pul-
satile waveform after occlusion of the venous limb.10
A systolic pressure index of less than 0.57 is more
commonly found in patients with ischemic steal syn-
drome. In one study, abnormal nerve conduction
studies were more common with progressively
lower systolic pressure indexes supporting ischemia
as a cause of some neuropathic symptoms.7 In
another study, a digital to brachial artery pressure
less than 0.6 had the best test characteristics for the
ischemic steal syndrome.5 However, in most
reports, there is considerable overlap in these physi-
ological tests between symptomatic and asymptom-
atic patients,5,7 thus these tests need to be inter-
preted in the appropriate clinical setting.
Neuropathies in the differential diagnosis
Severe neuropathic syndromes occurring shortly
after fistula creation require urgent attention. Ische-
mic monomelic neuropathy is a rare cause of
sensory-motor impairment of the forearm without
tissue necrosis. The initial case reports consisted of
sudden and permanent sensory and motor
impairment involving multiple nerve groups of a
distal limb and were associated with nerve conduc-
tion studies showing axonal loss and reduced con-
duction velocities.1517 Cases occurring immediately
after fistula creation were thought to be due to a
transient reduction in blood flow that caused ische-
mia of the vasa nervorum, but was not prolonged
enough to cause tissue loss.7,15,1719 It is most com-
monly associated with diabetes, atherosclerotic vas-
cular disease, and upper arm fistulae. Immediate
revascularization or ligation of the fistula is required
for this acute presentation, but may not prevent per-
manent nerve damage.15,17
Involvement of all of the distal nerves of the fore-
arm (radial, ulnar and median nerves) with
decreased nerve conduction studies and axonal loss
distinguish ischemic monomelic neuropathy from
focal nerve injuries such as hematoma, abscess, or
venous aneurysm that tend to affect only one
nerve.19,20 Carpal tunnel syndrome tends to be
more common in the fistula arm than the contralat-
eral arm, but is distinguished by an abnormal nerve
conduction study affecting primarily the median
nerve.21
A more indolent and less severe form of ischemic
monomelic neuropathy may occur, and one group
suggests that the diagnosis may be more likely with
a progressive decline in serial nerve conduction
374 P Zamani et al.
studies over several months associated with a
reduced systolic pressure index (< 0.5).7 In this set-
ting, revascularization may improve the neurologi-
cal symptoms.7
Tests to localize the cause of steal
Non-invasive and invasive testing has an important
role in determining any potentially reversible causes
of the ischemic steal syndrome. Imaging with ultra-
sound or arteriography (conventional, computed
tomography, or magnetic resonance techniques)
can assess proximal inflow and outflow disease in
addition to fistula flow rates.10
Duplex ultrasound can assess whether there is any
fistula inflow or outflow disease. Functional fistulae
usually have flow rates of greater than 600 ml/min,10
and fistulae with flow rates of < 250 ml/min are
more likely to thrombose. Since flow rates are exag-
gerated and often non-laminar in the inflow artery,
manual occlusion of the venous limb of the fistula is
usually required to see the typical post-stenotic
blunted or monophasic flow velocity, suggesting a
proximal arterial stenosis.18 Increased flow veloci-
ties or absent flow in the distal arteries of the fore-
arm suggest intrinsic disease distal to the fistula as a
cause of ischemic steal syndrome.
Marked reverse flow in the radial artery distal to
the fistula may cause ischemia. Demonstration of a
patent ulnar artery and palmar arch is required prior
to considering embolization or ligation of the radial
artery distal to the fistula to prevent hand steal.
Indications for revascularization
The indications for revascularization are:
1) any proximal inflow disease with poor fistula
flow
2) rest pain, muscle weakness, or necrosis in the
hand5,7,8,18,19
3) ischemic monomelic neuropathy7,18,19
Treatment of disease proximal or distal to the
fistula
Proximal artery disease can be treated by percutane-
ous methods, as in our case, or by surgical revascu-
larization. Percutaneous methods for proximal dis-
ease offer less morbidity, and as many patients with
ischemic steal syndrome have co-existing athero-
sclerotic vascular disease, probably less mortality
than surgery.22
Flow-limiting disease distal to the fistula can be
treated by angioplasty,11 or by surgical bypass that
may be part of a surgical revision of the fistula.
Severe hand steal from a radiocephalic fistula due
Vascular Medicine 2009; 14: 371376
to reverse flow in the more distal radial artery can be
treated by percutaneous radial artery embolization
12
or ligation (distal radial artery ligation, DRAL),
18,23 providing there is antegrade flow in the ulnar
artery and an adequate palmar arch.
Methods to modify the fistula
Surgical revision of the fistula improves distal blood
flow by redirecting flow from the fistula to the hand
or by improving collateral flow to the hand. Tech-
niques that reduce the diameter of fistula and/or
lengthen the fistula increase resistance and decrease
flow in the fistula according to Poiseuilles law.2,13
The DRIL procedure (see below) increases distal
flow by creating a low resistance collateral circuit
to the distal hand.10
Fistula banding
Fistula banding or plication aims to increase the
resistance of the fistula to divert flow down the
native artery (Figure 2). However, this reduces
flow in the fistula and threatens its survival. As a
result, many reports of banding show high rates of
fistula thrombosis.4,8 Intraoperative pressure or
flow monitoring may improve the success of the
procedure while preserving fistula flow. In one
series, distal artery flow was monitored by digital
plethysmography to achieve a digital pressure of
greater than 50 mmHg and a digital to brachial
pressure index greater than 0.69. This approach
relieved steal symptoms in all 16 patients, but only
10 (63%) had satisfactory graft function for more
than 6 months.9 Another approach is to monitor
the flow reduction in the venous limb of the fistula
to prevent severe flow reductions that would pro-
mote fistula thrombosis.24 In a series of 78 patients
with ischemic steal syndrome and high fistula flow,
banding was tailored to reduce fistula flow to
400 ml/min in autogenous grafts, and 600 ml/min in
prosthetic grafts. Ischemic symptoms were relieved in
86% of patients with 91% of autogenous fistulae
remaining patent at 12 months.24 Graft survival
with banding was less successful with prosthetic
grafts (only 58% patent at 1 year) and the authors
suggested that higher flow rates (> 750 ml/min) in
the graft were required to prevent thrombosis.24
More recently, the minimally invasive limited
ligation endoluminal-assisted revision (MILLER)
technique describes a modified method of
banding.25 In this procedure, the fistula is exposed
and a 45 mm balloon is introduced into the fistula
and inflated. A non-resorbable suture is tied around
the inflated balloon and vein to achieve a defined
reduction in balloon diameter. In the original report
of 16 patients, all had improvement in symptoms,
two required further revision of their fistulae and

Figure 2 Diagrams illustrating several methods to reduce distal artery steal by the arterial venous fistula. (DRIL, distal
revascularization, interval ligation; RUDI, revision using distal inflow; PAI, proximal arterial inflow graft.)
all were patent at a mean of 3 months of
follow-up.25
Distal revascularization, interval ligation (DRIL)
In this procedure, the artery distal to the fistula is
ligated to prevent reversal of flow in the distal
artery, and a bypass graft is placed from the brachial
artery well above the fistula to the antecubital or
forearm artery distal to the ligation (DRIL)
(Figure 2).26 The DRIL procedure effectively acts
as a low-resistance collateral artery to the distal
arm10 and improves symptoms in over 90% of
patients, while preserving the fistula in 73100%
of cases.2,14,18,27,28 The potential disadvantages of
DRIL are that the distal arm is dependent on a
graft for blood supply because the native artery is
ligated, and that distal anastomoses are technically
more difficult in patients with diffuse disease in the
distal forearm arteries.
Revision using distal inflow (RUDI)
The RUDI is designed to treat ischemic steal syn-
drome with a brachial artery fistula. In contrast to
ligating the native artery, RUDI ligates the fistula at
its origin and creates a bypass to the fistula from one
of the more distal forearm arteries (Figure 2).13 The
other forearm artery (not used as the graft source)
must be patent to prevent recurrence of a steal syn-
drome. RUDI tends to reduce flow in the fistula and
long-term patency and flow rates in large series have
not been reported.
Proximal arterial inflow (PAI)/proximal
arteriovenous anastomosis (PAVA)
The PAI or PAVA procedure moves the origin of the
fistula more proximally in the arm.29 The fistula is
ligated at its origin and a PTFE graft is run from the
more proximal brachial or axillary artery to the fistula
(Figure 2). By moving the graft feeder more proxi-
Vascular Medicine 2009; 14: 371376
Ischemic steal syndrome 375
mally to a larger artery, relative flow into the native
artery and collaterals is increased without compromis-
ing fistula flow volumes.29 In one case series of 30
patients, 84% were free of ischemic symptoms and
87% of the fistulae were patent at 12 months.29
Ligation of the fistula
When other treatment options fail or extensive vas-
cular calcification prevents revascularization or fis-
tula modification, ligation of the fistula can resolve
the ischemic symptoms, but with the need to create
another vascular access.
Conclusions
Ischemic steal syndrome causing symptoms after arm
fistula creation are rare but challenging to manage.
In our case example, decreased flow in the fistula was
initially thought to be due to a fistula stenosis.
Although angioplasty improved fistula flow, it exac-
erbated steal to cause hand ischemia and ultimately
digital infarction. This prompted investigation of
vascular causes of insufficiency beyond the fistula.
Although the diagnosis of ischemic steal syn-
drome is principally clinical, abnormal digital
pressures or pulse volume recordings support the
diagnosis by quantifying the severity of vascular
steal. The diagnosis can be distinguished from neu-
ropathic pain by nerve conduction studies. Abnor-
mal nerve conduction studies in all three distal
nerves of the forearm are more characteristic of
ischemic monomelic neuropathy.
The cause of the ischemic steal syndrome should
be directed at localizing disease from the aorta to
the hand. Duplex ultrasound and arteriography
should aim to interrogate the arteries proximal
and distal to the fistula in addition to fistula flow.
376 P Zamani et al.
Our case illustrates the pitfalls of focusing only on
the fistula as a cause of reduced fistula flow, as a
more severe proximal lesion was not considered in
the initial workup. In our case, subsequent recogni-
tion of the subclavian artery occlusion led to
successful angioplasty and stenting borrowing tech-
niques familiar to those employed in crossing coro-
nary artery occlusions. In the absence of proximal
or distal disease, several surgical techniques to mod-
ify the fistula or collateral flow to the hand can suc-
cessfully treat the ischemic steal syndrome while
preserving the fistula.
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