Hand Pain in Hemodialysis Patients Distal hypoperfusion Ischemic Syndrome

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1 Hand Pain in Hemodialysis Patients Distal hypoperfusion Ischemic Syndrome Arif Asif, M.D. Associate Professor of Medicine Director, Interventional Nephrology University of Miami Miller School of Medicine Miami, Florida

2 Hand Ischemia Reported incidence 1-8% More common in proximal accesses Hand pain (off and/or on dialysis) Cold hand Numbness Tissue necrosis

3 Pathophysiology Stealing of blood Fistula Low resistance Steal Distal brachial artery Proximal brachial artery Antegrade flow Retrograde flow Brachiobasilic Fistula

4 Strategies to Ameliorate Arterial Steal Reduction in the size of anastomosis Banding/Plication Insertion of tapered grafts Insertion of V-Clips Miller procedure Prevent Steal

5 However

6 Pathophysiology Nearly 70% of the distal fistulae and over 80% of the proximal fistulae normally demonstrate evidence of steal yet have no symptoms. Kwun et al: Vasc Surg 13: , 1979 De Massi et al: J Vasc Tech 18: , 1994 Duncan et al:. J Vasc Surg 4: , 1986

7 Proximal brachial artery It seems that it is normal to have Fistula steal in a Distal brachial artery majority of fistulae Kwun et al: Vasc Surg 13: , 1979 De Massi et al: J Vasc Tech 18: , 1994 Duncan et al:. J Vasc Surg 4: , 1986

8 Then steal is not the major mechanism of hand ischemia Only a small number of patient might have excessive steal (true steal) to induce ischemia Asif et al: Am J Kidney Dis 48:88-97, 2006 Valgi et al: Radiology 196: , 1995

9 There might be other mechanisms that are capable of producing hand ischemia

10 Arterial stenoses? By increasing resistance arterial stenoses can severely limit distal blood flow in a system

11 Arterial Stenoses A significant number (8-10%) of patients presenting with dialysis access dysfunction have a PURE ARTERIAL LESIONS - Khan and Vesely: J Vasc Interv Radiol 13: , Asif A, Gadalean N, Merrill D, et al: Kidney Int 67: , Duijm et al: Am J Kidney Dis 48:98-105, 2006

12 Arterial Stenoses and Arterial Steal Syndrome Underlying obstructive arterial stenoses as a cause of peripheral ischemia in HD patients has been documented Using comprehensive arteriography, these studies have reported the incidence of arterial stenosis to range from % Valgi et al: Radiology 196: , 1995 Guerra et al: Nephrol Dial Transplant 17: , 2002 De Caprio et al: Cardiovasc Surg 5: , 1997

13 a b c d

14 Does Arterial Angioplasty Work?

15 Arterial Angioplasty A recent retrospective study of arterial angioplasty in dialysis access included 10 patients with severe limb ischemia 8/10 became symptoms free after the application of PTA Guerra et al: Nephrol Dial Transplant 17: , 2002

16 Patients presenting with hand ischemia Prospective Study n=12 Asif et al: Am J Kidney Dis 48:88-97, 2006

17 We need a fresh approach to the pathophysiology of hand ischemia

18 Pathophysiology True stealing of blood into the low resistance area Presence of stenotic lesions

19 Generalized Arterial Disease Vascular calcification (1) Intima and media are affected PTA and surgery are not helpful Avoidance of calcium overload and maitaninance of good mineral metabolic balance and dialysis are the mainstay of treatment Kim YO, Song HC, Yoon SA et al: Am J Kid Dis 41: , 2003

20 Generalized Arterial Disease Asif et al: Am J Kidney Dis 48:88-97, 2006

21 Pathophysiology of Hand Ischemia True Steal Arterial Stenosis Generalized Arteriopathy

22 Reevaluating Arterial Steal Syndrome True stealing of blood into the low resistance area (can be called as steal syndrome) Presence of stenotic lesions (can NOT be called STEAL) Generalized arteriopathy (can NOT be called STEAL)

23 Reevaluating Arterial Steal Syndrome A more appropriate terms might be Distal Hypoperfusion Ischemic Syndrome (DHIS) Leon and Asif: CJASN January 2006

24 Distal Hypoperfusion Ischemic Syndrome (DHIS); Ischemic Monomelic Neuropathy (IMN); Carpel Tunnel Syndrome (CTS); Destructive Arthropathy (DA). Leon and Asif: CJASN January 2006

25 Management Proposal Leon and Asif: CJASN 2006

26 Summary True steal, stenosis and generalized arteriopathy can cause hand ischemia. Complete imaging of the arterial circulation (Aortic arch to Palmar arch) of the extremity be considered to disclose the cause of hand ischemia Planning and application of corrective procedures should be based on the findings of arteriography A team approach among nephrologists, interventionalists and surgeons would improve patient care

27 NOTES 2. Shown here are the common clinical features of patients presenting with hand ischemia. 3. Traditionally, stealing of blood into the arteriovenous access (low resistant area) has been highlighted to be THE cause hand ischemia. 4. Because of stealing concept, a great majority of interventions to ameliorate hand ischemia have focused on reducing flow through the anastomosis and juxta-anastomotic region. 6. However, a great majority of forearm and upper arm fistulae normally demonstrate the evidence of steal. 7. Many studies have shown that stealing of blood into the arteriovenous access is normal in a great majority of patients. Consequently, is not a major reason for hand ischemia. Excessive steal might occur in a minority of patients and cause hand ischemia. 12. Many studies have demonstrated that arterial stenoses can cause hand ischemia. 13. Arterial stenotic lesions can occur in proximal and peripheral arteries. Axillary artery (a), brachial artery (b,c) and radial artery (d). 16. Role of angioplasty in the management of hand ischemia. 18. Presence of arterial stenotic lesions play a role in the pathophysiology of hand ischemia. A minority of patients with hand ischemia might be due to excessive steal. 19. In addition, generalized arteriopathy might also contribute to hand ischemia. 20. Calcified arteries are shown. 21. It seems that there are three separate mechanisms that can cause hand ischemia. 22. Since there are three different mechanisms, we can not call hand ischemia steal syndrome. 24. Differential diagnosis must be considered. 25. A simple algorithm for the management of patients with hand ischemia.