Understanding the Hemodynamics Involved in Ischemic Steal Syndrome of Arteriovenous Access

Highlights

• This paper elucidates the significant role retrograde steal plays in the pathogenesis of ischemia by reviewing the successful outcomes achieved by widely employed surgical procedures.

• These successful interventions share an important hemodynamic feature to reverse distal ischemia: namely, the conversion of straight access configuration to a loop configuration.

• This conversion reduces retrograde steal, thereby increasing distal pressure and flow, resulting in the successful treatment of ischemic steal syndrome.

Abstract

Long-term hemodialysis, the main treatment modality for patients with end-stage renal disease, requires reliable vascular access. The arteriovenous fistula is the preferred access but remains susceptible to complications, among which ischemic steal syndrome is the most serious. The pathophysiology of ischemic steal syndrome results from the diversion of arterial flow, antegrade, retrograde, or both, into the access.

Although antegrade diversion alone can cause steal syndrome, retrograde diversion plays a significant role in the development of ischemia, especially in patients with distal brachial artery-based access.

Recently, the role of retrograde steal was disputed, but this paper will elucidate the significant role of retrograde steal in the pathogenesis of ischemia by reviewing the successful outcomes achieved by widely employed surgical procedures. These successful interventions share an important hemodynamic feature to reverse distal ischemia: namely, the conversion of a straight access configuration to a loop configuration. This conversion reduces retrograde steal, thereby increasing distal pressure and flow, resulting in the successful treatment of ischemic steal syndrome.