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      The Hemodialysis Patient and Hand Amputation

      American Journal of Nephrology

      S. Karger AG

      Arteriovenous fistula, Hemodialysis surgery, Hand ischemia

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          The hemodialysis patient requires continued attention once an access surgery has been performed. These procedures lead to an anticipated physiological steal in the involved hand, but rarely lead to hand loss. When the patient has had previous peripheral vascular disease, known diabetes mellitus, multiple interventions on the same extremity, and the use of a synthetic graft, the incidence of digital or hand ischemia is significantly increased. This article represents 3 individuals who required hand amputation for severe ischemia. The pertinent clinical features in each individual will be explained and the literature reviewed for the factors promoting this complication and the all-autogenous access policies which may help to prevent hand ischemia.

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          Most cited references 8

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          Chronic renal failure--a vasculopathic state.

           R K Luke (1998)
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            Steal syndrome complicating hemodialysis access procedures: can it be predicted?

            The development of steal syndrome distal to an arteriovenous fistula (AVF) created for hemodialysis access remains a significant clinical problem. This study was undertaken to determine the role of intraoperative noninvasive testing in the prediction and management of steal syndrome following arteriovenous fistula creation. First, in order to determine a threshold digital/brachial index (DBI) for patients at risk for steal syndrome, we performed a retrospective review of patients who had had the DBI measured and who developed symptoms (steal syndrome) following AVF creation. This was followed by a prospective evaluation of the ability of the DBI to predict which patients undergoing AVF surgery would develop steal syndrome. A DBI of 0.6. Failure to accomplish this puts the patient at risk for continued steal syndrome.
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              Incidence of the radial steal syndrome in patients with Brescia fistula for hemodialysis: its clinical significance.

              The Brescia fistula is the method of choice for providing vascular access in patients who have chronic kidney failure that requires hemodialysis. This study investigated hand hemodynamics in patients with Brescia fistulas to determine the incidence of radial steal and its relationship to symptoms of arterial insufficiency of the hand. Twenty-three patients, one of whom had symptoms of arterial insufficiency, were studied. Thumb systolic blood pressure was determined by photoplethysmography under resting conditions and with the fistula, radial, and ulnar arteries occluded successively by digital pressure. The brachial pressure was determined by Doppler ultrasonography and the thumb/arm pressure ratio was determined for each experimental condition. The presence of a Brescia fistula resulted in a 40% reduction of the thumb blood pressure (median thumb/arm ratio = 0.61), which returned to normal (median ratio = 1.03) when the fistula was occluded. Occlusion of the radial artery distal to the fistula resulted in a significant increase in thumb blood pressure (median ratio = 0.89; p less than 0.001), indicating the presence of radial steal. This phenomenon occurred in 21 of the 24 fistulas (88%) studied. This study demonstrated that the radial steal phenomenon occurs in most patients with Brescia fistulas but in only a small number of these patients do symptoms of arterial insufficiency develop.

                Author and article information

                Am J Nephrol
                American Journal of Nephrology
                S. Karger AG
                December 2001
                28 December 2001
                : 21
                : 6
                : 498-501
                Danville Vascular Surgery, Danville, Va., USA
                46656 Am J Nephrol 2001;21:498–501
                © 2001 S. Karger AG, Basel

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                Page count
                References: 26, Pages: 4
                Self URI (application/pdf):
                Case Report

                Cardiovascular Medicine, Nephrology

                Hand ischemia, Hemodialysis surgery, Arteriovenous fistula


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