Partial excision of brachial arterio-venous fistula body and venous limb to treat steal syndrome in haemodialysis patients

Background
Steal syndrome is one of the complications of dialysis arterio-venous fistula (AVF) characterized by decrease digital arterial pressure from preferential blood flow through the low pressure venous outflow. It has clinical importance when leading to hand ischaemia, heart overload, or both. High flow steal has the distal upper limb arteries intact. Treatment options include ligation, change fistula inflow, and banding procedures. Partial fistula excision and reclosure is a technique that tries to limit the AVF hyperfunction to improve hand ischaemia.
Aim of the work
To assess feasibility, outcome, and complications of partial shunt excision to treat hyperfunctioning steal.
Patients and methods
The study included 20 patients, 12 women and 8 men, with high flow steal hand ischaemia from September 2018 to December 2020. Preoperative duplex assessment of fistula outflow volume and wrist arteries was performed. All patients had partial fistula body and outflow excision, resizing, and suture closure in 3-month follow-up for clinical and duplex outcome.
Results
Significant decrease of fistula outflow volume after the procedure from 1847.50 ± 656.04 to 1258.50 ± 413.93 and increase in wrist arterial peak systolic velocity from 23.50 ± 8.64 to 56.80 ± 15.03 (=0.002 and <0.002), respectively, were found. Complete relief of hand ischaemic symptoms in 75% of patients, partial improvement in 25% with minimal postoperative complications, no reintervention, and no limb loss during follow-up with 3-month 100% patency was noted.
Conclusion
Partial shunt excision is a feasible flow limiting procedure that can treat high flow AVF effectively with minimal complication.