Strategies for Predicting and Treating Access Induced Ischemic Steal Syndrome

Access induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. A number of clinical risk factors have been identified to select patients at risk. Intraoperative measurement of the digital–brachial index may further distinguish at-risk patients when the DBI is <0.45. Once clinically significant steal has developed, surgical strategies to treat this problem should ideally reverse the ischemia while maintaining uninterrupted access for hemodialysis. To date, the distal revascularization–interval ligation or DRIL procedure has been the most consistently successful tactic in achieving these dual objectives. A number of alternative strategies have recently been proposed and will be discussed.