Biagetti Gina M, Carpiniello Matthew F, Dougherty Matthew J, Troutman Douglas A, Calligaro Keith D
Department of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
Department of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
J Vasc Surg. 2025 Feb;81(2):459-464.e1. doi: 10.1016/j.jvs.2024.09.035. Epub 2024 Oct 9.
Dialysis access-associated steal syndrome (DASS) is one of the most serious complications of hemoaccess surgery. Treatment algorithms involve significant morbidity; a tool to reliably identify patients at risk who could benefit from interventions at time of operation would be useful. We present a strategy of using perianastomotic pressure (PAP) measurement to identify patients who may be at high risk of developing DASS.
Patients who underwent dialysis access creation between January 1, 2018, and September 30, 2022, at our institution were reviewed. Beginning in October 2019, we developed a strategy of measuring systolic pressure at the arterial anastomosis intraoperatively. A ratio of this value compared with the systemic systolic pressure was calculated. In patients believed to be at high risk for developing DASS based on clinical findings, selective banding of the access was performed intraoperatively to augment distal perfusion.
Of 857 total patients, 36 (4.2%) developed clinically significant DASS, defined as requiring operative treatment, either intraoperatively or during follow-up (mean, 76 days; range, 0-602 days). DASS was more common for femoral-based accesses (6/12 [46.2%]) compared with upper extremity accesses (30/840 [3.6%]; P < .001). No patients who underwent radiocephalic arteriovenous fistula or infraclavicular axillary arteriovenous graft construction developed DASS. There was no difference in DASS for upper extremity arteriovenous fistulas (20/576, 3.47%) vs AV grafts (10/264, 3.79%; P = .82). There were 216 patients who had PAP measured intraoperatively. Fourteen (6.5%) of these 216 patients developed DASS requiring intervention in follow-up. The mean PAP ratio of these 14 patients was 0.395 vs 0.557 for the 202 patients who did not (95% confidence interval, 0.07-0.25; P = .001). Seventeen patients who had a low PAP ratio with poor distal perfusion underwent intraoperative banding, which improved the mean PAP ratios from a mean of 0.33 to 0.58. Despite banding, 3 of these 17 patients (17.6%) in this high-risk subgroup went on to develop DASS postoperatively. The calculated mean PAP ratio in patients who either developed DASS postoperatively or underwent prophylactic banding intraoperatively was 0.37, which was significantly lower than the mean ratio of 0.57 in the control group (P = .001).
Low PAP ratios (<0.50) identified patients at increased risk for DASS, but prophylactic banding did not always prevent the occurrence of DASS in select patients. Because steal is a dynamic phenomenon, intraoperative conditions are not always going to reflect later adaptation. Nonetheless, PAP measurement may identify a subgroup of patients warranting procedural modification or closer postoperative physiological monitoring.
透析通路相关盗血综合征（DASS）是血液透析通路手术最严重的并发症之一。治疗方案存在较高的发病率；一种能够可靠识别有风险且可能从手术干预中获益的患者的工具将很有用。我们提出一种利用吻合口周围压力（PAP）测量来识别可能发生DASS高风险患者的策略。
回顾了2018年1月1日至2022年9月30日在我院接受透析通路建立的患者。从2019年10月开始，我们制定了术中测量动脉吻合口收缩压的策略。计算该值与体循环收缩压的比值。对于根据临床发现被认为发生DASS高风险的患者，术中进行选择性通路绑扎以增加远端灌注。
在857例患者中，36例（4.2%）发生了具有临床意义的DASS，定义为术中或随访期间需要手术治疗（平均76天；范围0 - 602天）。与上肢通路相比，基于股部的通路发生DASS更常见（6/12 [46.2%]）（上肢通路30/840 [3.6%]；P <.001）。接受头静脉桡动脉内瘘或锁骨下腋动脉移植物构建的患者均未发生DASS。上肢动静脉内瘘（20/576，3.47%）与动静脉移植物（10/264，3.79%）发生DASS的情况无差异（P =.82）。216例患者术中测量了PAP。这216例患者中有14例（6.5%）发生DASS，需要在随访中进行干预。这14例患者的平均PAP比值为0.395，而未发生DASS的202例患者为0.557（95%置信区间，0.07 - 0.25；P =.001）。17例PAP比值低且远端灌注差的患者术中进行了绑扎，使平均PAP比值从平均0.33提高到0.58。尽管进行了绑扎，该高风险亚组中的这17例患者中有3例（17.6%）术后仍发生了DASS。术后发生DASS或术中接受预防性绑扎的患者计算出的平均PAP比值为0.37，显著低于对照组的平均比值0.57（P =.001）。
低PAP比值（<0.50）可识别发生DASS风险增加的患者，但预防性绑扎并不总能防止特定患者发生DASS。因为盗血是一种动态现象，术中情况并不总是能反映后期的适应性变化。尽管如此，PAP测量可能识别出需要进行手术调整或术后更密切生理监测的患者亚组。
