Division of Vascular Surgery, North Shore University Health System, 9977 Woods Dr., Ste. 355, Skokie, IL 60077, USA.
J Vasc Surg. 2011 Jul;54(1):162-7. doi: 10.1016/j.jvs.2010.10.134. Epub 2011 Jan 26.
Ischemic steal syndrome (ISS) associated with arteriovenous (AV) access is rare but can result in severe complications. Multiple techniques have been described to treat ISS with varying degrees of success. This study compares the management and success associated with these techniques.
Patients with ISS between June 2003 and June of 2008 at the University of Pittsburgh Medical Center were retrospectively reviewed. Demographics, type of AV access, management technique, and success of intervention were recorded. Success was defined as resolution of ISS symptoms while preserving access function. One hundred consecutive AV access procedures were reviewed for comparison. Data were analyzed using χ(2) test, Fisher's exact test, and Student's t test. The study was approved by our institutional review board.
A total of 114 patients with ISS had a mean age of 65 years (range, 20-90 years), were predominantly female (66%), diabetic (61%), and with a brachial origin fistula (69%). Risk factors for ISS included coronary artery disease (CAD; P < .001), hypertension (P < .001), and tobacco use (P = .048). Women were noted to have a brachial origin access more frequently than men (odds ratio [OR], 3.1; P = .009). Forty-four patients with mild steal were observed. Seventy patients underwent 87 procedures. Procedures performed included ligation (n = 27), banding (n = 22), distal revascularization and interval ligation (DRIL; n = 21), improvement of proximal inflow (n = 9), revision using distal inflow (RUDI; n = 4), and proximalization of arterial inflow (PAI; n = 3). Early procedures (<30 days from the index fistula) were mostly ligation (50%) or banding (38%), while DRIL was the most frequent choice for late interventions (41%). Banding had a high failure rate (62%) and was the most common reason for reintervention (8 of 11, 73%) and DRIL had a better success rate than banding (P ≤ .05). In our current practice, 18% of patients had an AV fistula with the proximal radial artery (PRA) as the inflow source, while this type of fistula accounted for only 2% of all ISS patients. Ligation resolved symptoms in all patients, but the AV access was lost.
Risk factors for development of ISS include CAD, diabetes, female gender, hypertension, and tobacco use. Among various options to treat ISS, banding has a low success rate and high likelihood for reintervention, while DRIL is particularly effective although not uniformly. Less invasive treatment options such as RUDI and PAI may be quite effective in treating ISS. Use of the PRA as the inflow source may decrease the incidence of ISS.
与动静脉（AV）通路相关的缺血性窃血综合征（ISS）很少见，但可能导致严重的并发症。已经描述了多种技术来治疗 ISS，其成功率也有所不同。本研究比较了这些技术的管理和成功率。
回顾性分析 2003 年 6 月至 2008 年 6 月期间在匹兹堡大学医学中心接受治疗的 ISS 患者。记录患者的人口统计学、AV 通路类型、管理技术和干预成功率。成功定义为 ISS 症状缓解，同时保留通路功能。比较了 100 例连续的 AV 通路手术。数据采用 χ(2)检验、Fisher 确切概率法和学生 t 检验进行分析。本研究得到了我们机构审查委员会的批准。
共有 114 例 ISS 患者，平均年龄 65 岁（范围，20-90 岁），主要为女性（66%）、糖尿病（61%）和肱动脉起源瘘（69%）。ISS 的危险因素包括冠状动脉疾病（CAD；P <.001）、高血压（P <.001）和吸烟（P =.048）。与男性相比，女性更常出现肱动脉起源通路（优势比[OR]，3.1；P =.009）。44 例患者有轻度窃血，70 例患者接受了 87 次手术。手术包括结扎（n = 27）、绑扎（n = 22）、远端血运重建和结扎（DRIL；n = 21）、近端血流改善（n = 9）、远端血流改良（RUDI；n = 4）和近端动脉血流改道（PAI；n = 3）。早期手术（指数瘘管形成后 30 天内）多为结扎（50%）或绑扎（38%），而 DRIL 是晚期干预的最常见选择（41%）。绑扎的失败率较高（62%），是再次干预的最常见原因（8 例中有 11 例，73%），DRIL 的成功率高于绑扎（P ≤.05）。在我们目前的实践中，18%的患者的 AV 瘘采用近端桡动脉（PRA）作为血流来源，而 ISS 患者中只有 2%采用这种类型的瘘管。结扎术可缓解所有患者的症状，但 AV 通路丧失。
ISS 的发展危险因素包括 CAD、糖尿病、女性、高血压和吸烟。在治疗 ISS 的各种选择中，绑扎的成功率较低，再次干预的可能性较大，而 DRIL 虽然效果不理想，但成功率较高。RUDI 和 PAI 等侵袭性较小的治疗选择可能对 ISS 的治疗非常有效。使用 PRA 作为血流来源可能会降低 ISS 的发生率。
