Of those presenting with hand pain, 7 out of 10 patients were found to accurately depict the presence of arterial stenoses. Imaging revealed 3 cases of excessive flow into the access via the arterial anastomosis. To assess for the presence of arterial stenosis in patients with a hemodialysis access who have presented with clinical concern for peripheral ischemia, one study (n = 13) reports using complete arteriography to image from the aortic arch to the palmar arch [136]. They concluded that 62% of the 13 patients who underwent referrals for assessment for steal syndrome were found to have a hemodynamically significant (>50%) arterial stenosis. Another study (n = 5) reveals that a culprit stenosis in the inflow arterial circulation was imaged in 100% of the patients undergoing complete arteriography [137]. Lazarides et al [138] touts that arteriography is not a prerequisite for the diagnosis and management of DHIS. They consider the return of radial or ulnar pulses with associated manual compression of the graft as the sole requisite factor required to confirm the diagnosis. They utilized an empiric threshold level of systolic pressure index <0.5 to denote abnormal nerve conduction studies, marked by a positive predictive value of 75%. In 94% of their studied patients, distal ischemia was detected by a systolic pressure index <0.8 to some degree. In patients with systolic pressure index <0.5, these were most likely to have impaired nerve conduction studies. US Duplex Doppler Hemodialysis Access Area of Interest The changes noted on US examination are not diagnostic of a clinical steal syndrome. However, they can illustrate the presence of a steal phenomenon in settings where DASS or DHIS is clinically suspected. For example, there may be reversal of the blood flow distal to the arterial anastomosis (flow towards the fistula) or it may be Dialysis Fistula Malfunction bidirectional with or without evidence of DASS [139].
Dialysis Fistula Malfunction. Of those presenting with hand pain, 7 out of 10 patients were found to accurately depict the presence of arterial stenoses. Imaging revealed 3 cases of excessive flow into the access via the arterial anastomosis. To assess for the presence of arterial stenosis in patients with a hemodialysis access who have presented with clinical concern for peripheral ischemia, one study (n = 13) reports using complete arteriography to image from the aortic arch to the palmar arch [136]. They concluded that 62% of the 13 patients who underwent referrals for assessment for steal syndrome were found to have a hemodynamically significant (>50%) arterial stenosis. Another study (n = 5) reveals that a culprit stenosis in the inflow arterial circulation was imaged in 100% of the patients undergoing complete arteriography [137]. Lazarides et al [138] touts that arteriography is not a prerequisite for the diagnosis and management of DHIS. They consider the return of radial or ulnar pulses with associated manual compression of the graft as the sole requisite factor required to confirm the diagnosis. They utilized an empiric threshold level of systolic pressure index <0.5 to denote abnormal nerve conduction studies, marked by a positive predictive value of 75%. In 94% of their studied patients, distal ischemia was detected by a systolic pressure index <0.8 to some degree. In patients with systolic pressure index <0.5, these were most likely to have impaired nerve conduction studies. US Duplex Doppler Hemodialysis Access Area of Interest The changes noted on US examination are not diagnostic of a clinical steal syndrome. However, they can illustrate the presence of a steal phenomenon in settings where DASS or DHIS is clinically suspected. For example, there may be reversal of the blood flow distal to the arterial anastomosis (flow towards the fistula) or it may be Dialysis Fistula Malfunction bidirectional with or without evidence of DASS [139].