SHM Converge Scientific Abstract ePoster Gallery-Delayed Ischemia in the Setting of Arteriovenous Fistula Steal Syndrome

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This case describes a 63-year-old man with severe left hand pain, swelling, and necrosis of the left fifth digit in the setting of long-standing end-stage renal disease on hemodialysis through a left arteriovenous fistula (AVF). He also had extensive vascular disease, including peripheral vascular disease with prior bilateral above-knee amputations and a recent right fourth digit amputation.<br /><br />Because of his pain, cold left hand, and tissue loss, the initial differential included cellulitis, chronic osteomyelitis, and peripheral vascular disease-related ischemia. Inflammatory markers were elevated, but the white blood cell count was normal and imaging showed no osteomyelitis. CTA demonstrated patent runoff to the wrist, which made severe peripheral arterial disease less likely. Despite consultation with nephrology, orthopedics, and vascular surgery, dialysis access-associated steal syndrome (DASS) was initially felt to be unlikely.<br /><br />A fistulogram ultimately confirmed DASS by showing improved arterial opacification when the dialysis fistula was compressed, proving that blood flow was being diverted through the AVF and away from the hand. The patient underwent fistula ligation and amputation of the necrotic fifth digit. After treatment, his remaining fingers became warm and well perfused, and his pain and range of motion improved.<br /><br />The report emphasizes that DASS is a rare but serious complication of hemodialysis access that can cause hand ischemia, distal necrosis, gangrene, and amputation. It may occur soon after fistula creation or many years later. Because symptoms can resemble other ischemic conditions, DASS should remain on the differential in any dialysis patient with hand pain, coolness, numbness, weakness, or poor perfusion. Early diagnosis using fistula compression with angiography or Doppler ultrasound is essential, and treatment may include ligation, banding, or revascularization.

Asset Subtitle

Alexandra Huet-Hudson

Meta Tag

Author List Alexandra Huet-Hudson, Jessica McCutcheon, Megan Donaldson

Category Clinical Vignettes

Concept Dialysis-Associated Steal Syndrome

Concept Hand Ischemia

Concept Hemodialysis Arteriovenous Fistula

Concept Distal Arterial Opacification

Concept Fistula Compression

Distinguished Non-Finalist

Presenter Organization Wake Forest School of Medicine

Presenting Author Alexandra Huet-Hudson

Track Adult

Keywords

dialysis access-associated steal syndrome

hemodialysis

arteriovenous fistula

hand ischemia

digital necrosis

fistulogram

vascular disease

fistula ligation

amputation

peripheral vascular disease

Dialysis-Associated Steal Syndrome

Hand Ischemia

Hemodialysis Arteriovenous Fistula

Distal Arterial Opacification

Fistula Compression