Management of finger gangrene caused by steal syndrome in vascular access for hemodialysis Personal experience and a brief review of the literature

INTRODUCTION: Severe dialysis-associated steal syndrome (DASS) is an uncommon and severe complication after arteriovenous fistula (AVF) creation that can lead to finger gangrene and amputation. As the number of patients on hemodialysis increases in western countries the number of patients at risk for DASS will continue to rise. METHODS: We retrospectively reviewed all patients who underwent a surgical intervention for the management of DASS with finger gangrene from January 2004 to July 2013. Demographic data, pre-operative work-up, procedure details and outcomes were collected. A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used. RESULTS: A total of nine patients were identified. Mean age was 53 years, 67% were women. All patients presented with finger tissue loss or gangrene. Surgical procedures included AVF closure/ligation (5), distal artery ligation (DRAL) (2), distal revascularization with interval ligation (DRIL) (1), banding (1). All patients had improvement of symptoms during follow-up. No major amputation occurred. CONCLUSIONS: Surgical interventions to correct DASS in patients with finger gangrene are mandatory while conservative management is not recommended. The decision for which type of procedure is made individually, according to clinical symptoms, technical findings, and patients' general state of health.