Treatment of vascular steal syndrome

Date written: August 2011

Author: Christine Russell

GUIDELINES
No recommendations possible based on Level I or II evidence

SUGGESTIONS FOR CLINICAL CARE

(Suggestions based on level III and IV evidence)

Patients with symptoms of steal should be investigated for inflow stenosis.

There are a number of surgical procedures that can be used in the treatment of steal – Distal
revascularisation interval ligation (DRIL) procedure is probably the most widely used and
durable, with preservation of the access.

IMPLEMENTATION AND AUDIT

Audit the number of patients developing steal syndrome, interventions and patient outcomes.

BACKGROUND
Patients with steal phenomenon can present with paraesthesia, pain, ulceration and tissue loss. Some
degree of steal is common, for example, in a questionnaire of 120 haemodialysis patients, 50% of
patients with a brachio-cephalic AVF reported a cold hand compared with 12% of those with a radio-
cephalic AVF [1]. Dialysis Access Steal Syndrome (DASS) requiring intervention has an incidence of
around 4%, although 10-20% of patients with AV fistulas or grafts may suffer some degree of ischaemia
causing pain or paraesthesia [2]. DASS tends to present earlier in patients with an AV graft (AVG)
compared to those with a native AV fistula (AVF). For example the study by Lazarides et al [3] reported
an average time interval from access construction to occurrence of DASS of 2 days for AVG’s and 165
days for AVF’s.

DASS is usually due to one or more of the following factors;

Inflow stenosis – defined as stenosis within the arterial system, artery-graft anastomosis (graft
cases), artery-vein anastomosis (fistula cases) and juxta-anastomotic region (the first 2 cm
downstream from the arterial anastomosis)[4]
Retrograde flow – back flow into the artery distal to the arteriovenous anastomosis and into the
arteriovenous access [5]
Distal arteriopathy – result of generalized vascular calcification due to diabetes [6]

It may also rarely be due to a high flow fistula in patients with otherwise normal vessels [2].

A grading scheme has been proposed by Sidaway et al [7].

Grade 0: No steal
Grade 1: Mild - cool extremity with no symptoms but steal demonstrated by flow augmentation with
access occlusion.
Grade 2: Moderate - intermittent ischaemia only during dialysis/claudication
Grade 3: Severe - ischaemic pain at rest/tissue loss

Alternatively the leg ischaemia grade has been proposed by Tordoir et al [8].
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Vascular Access July 2012 Page 1 of 16
 Stage 1: Pale/blue and/or cold hand without pain
Stage 2: Pain during exercise and/or haemodialysis
Stage 3: Rest Pain
Stage 4: Ulcers/necrosis/gangrene

The aim of this guideline is to develop recommendations by reviewing the available evidence on the
management of steal syndrome.

SEARCH STRATEGY
Databases searched: MeSH terms and text words for dialysis and haemodialysis were combined with
MeSH terms and text words for vascular steal syndrome. The search was carried out in Medline (1950
– August Week 1, 2011). The Cochrane Renal Trials Register was also searched for trials not indexed
in Medline.

Date of search/es: August 2011.

WHAT IS THE EVIDENCE?

There are no randomised controlled trials relating to the diagnosis and treatment of DASS. The
available evidence relating to causes, diagnosis and treatment of DASS are largely limited to case
reports and retrospective reviews of case series within single centres. Furthermore, only a few studies
have made comparisons between treatments and even fewer have included a control group. This limits
the ability to make recommendations. In addition reported studies do not take into account the need for
temporary access and associated complications. A summary of key studies contributing to the evidence
is presented in Table 1.

Can DASS be predicted?

The identification of risk factors for DASS and is limited to retrospective reviews of generally small
patient numbers within single centres.

The following is a summary from the available evidence:

1. Risk factors for DASS

a. Independent risk factors for DASS include [9-13]:
Female gender (OR 1.77, P=0.040) [9]
Tobacco use (OR 2.0, P=0.048) [9]
Diabetes (OR 1.9, P=0.048) [9]; (OR 5, P=0.01) [10]
Peripheral vascular disease (OR 2.3, P=0.008) [9]
Coronary artery disease (OR 2.7, P<0.001) [9]
Hypertension (OR 2.8, P<0.001) [9]
Trend with increasing age [10]
b. Inadequate arterial inflow [14].
c. Distal arteriopathy in arteries supplying the hand [6].
d. Upper arm AVF compared to forearm. For example in the study by Morsy et al the incidence of
DASS was 4.3% in patients with upper arm AVFs compared to 1.8% in patients with forearm
AVFs [15]; while Odland et al report an incidence of 1% for forearm AVFs [16]. In the review by
Gupta et al [9] patients with DASS were more likely to have an upper arm fistula (OR 4.5,
P<0.001).
e. Upper arm AVF compared to grafts [13].

2. The digital brachial index (DBI) measured after the fistula has been placed has been shown to be
predictive of patients who develop DASS. In a prospective study of 109 haemodialysis patients, the
DBI was 0.74 +/- 0.26 (range 0.30-1.63) vs. 1.01 +/- 0.23 (range 0.45-1.76) with the AVF occluded
in those who did not develop DASS. In patients who subsequently developed DASS, the DBI was
0.44 +/- 0.13 (range 0.24-0.58) (P < 0.001 versus the asymptomatic group) and 0.95 +/- 0.24 (range
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Vascular Access July 2012 Page 2 of 16
 0.64-1.24) with the AVF occluded (P > 0.10 versus the asymptomatic group). A DBI threshold of
<0.6 predicted DASS symptoms with a sensitivity of 100%, specificity 59% and a PPV of 18%) [17].
In another study of 35 patients with DBI measured pre-op, day of surgery and at 1 month, there was
no decrease at one month, compared to immediately post-op. DBI in patients without steal dropped
from 0.9 to 0.7. In those with symptomatic steal, DBI dropped from 0.8 – 0.4 (P < 0.01). Using DBI
<0.6, sensitivity was 100% [18]. Tynan-Cuisinier et al recommend a DBI cut off of <0.45 as a more
accurate predictor of significant DASS [19].

3. In a case-control study of 40 patients the change in digital pressure (CDP) with the fistula
compressed was significantly greater in DASS patients compared to the controls. However, as a
predictive test, CDP was less accurate than either DBI or basal digital pressure both of which were
significantly lower in DASS patients compared to the controls [20].

4. Pre-operative digital pressures were examined prospectively in haemodialysis patients with brachial
artery fistulas and grafts [13]. Of the 72 patients, 14 (19%) developed DASS. Those without DASS
had significantly higher finger pressures of 151 +/- 27mmHg compared to those who developed
DASS who had finger pressures of 131 +/- 31mmHg (P < 0.03). There was however, no absolute
threshold identified below which DASS was inevitable.

5. Retrograde flow is a common phenomenon in the artery just distal to the anastomosis in 80-90% of
all AV fistulas [2]. In a cross sectional study of 24 haemodialysis patients 21/24 (88%) of radio-
cephalic AVF’s had diminished thumb pressures with a radio-cephalic AVF, which improved with
compression of both the fistula and also the radial artery below the anastomosis. However, only one
of these patients had symptoms of arterial insufficiency (i.e. DASS) [21].

In another study with mostly upper arm AVF’s or grafts showed 44% flow reversal, which again did
not correlate with symptoms [22]. This study also looked at the reduction of mean peak systolic
velocities in radial and ulnar arteries after arm vascular access formation, and showed no statistical
correlation with change in any hand symptoms. Baseline peak systolic flow or post-op reduction in
peak systolic velocity also did not correlate with development of steal symptoms in this study.

How should steal be treated?

The available evidence relating to the treatment of DASS is largely limited to case reports and case
series from single centres. There are no randomised control trials and limited prospective studies.
Furthermore most studies are limited to single procedures. Where multiple procedures have been
reviewed, the numbers of some procedures are small thereby limiting the ability to make meaningful
comparisons between treatment options. Table 1 presents a summary of studies that include
assessment of outcomes associated with treatment using the following procedures [23]:

Ligation of the AV fistula and loss of access.

Angioplasty to treat proximal artery disease.
Banding to increase resistance of the fistula.
Distal revascularisation, interval ligation, where the artery distal to the fistula is ligated and a
bypass graft is placed well above the fistula.
Revision using distal inflow (RUDI), where the fistula is ligated at its origin with a bypass created
from one or more distal forearm arteries.
Proximal arterial inflow (PAI) procedure where the fistula is ligated at its origin and a PTFE graft
is run from the more proximal brachial or axillary artery to the fistula.

1. Ligation of the AV fistula. This usually results in loss of symptoms, but also the loss of the access
and therefore limited to severe cases of DASS [9, 11, 13, 24]. In the case of radio-cephalic end-to-
side fistulas, the radial artery can be ligated below the anastomosis if there is reversed flow.

2. In the prospective case series reported by Asif et al [14], complete arteriography was performed on
12 patients with DASS symptoms. Arterial stenosis was identified in 10 patients 8 of whom were
treated with angioplasty resulting in resolution of symptoms and access preservation in all 8
patients. The remaining patients were treated using surgical interventions.

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Vascular Access July 2012 Page 3 of 16
3. The DRIL procedure was first described in 1988 by Schanzer [25]. This has been shown to be the
best from a number of different configurations on the basis of theoretical flow modelling. An un-
tapered 6-mm prosthetic brachial-axillary access was selected as the prototype configuration, and
the theoretical effect of six access modifications on forearm flow was analysed. This showed that
theoretically, DRIL was the best procedure, followed by DR without ligation, and more proximal take
off procedure. [26]. One group has measured pressures at various points both before and after
DRIL and concluded that the improvement was due to a higher pressure at the point where the
blood supply to the hand and to the fistula divide, being higher up the arm [27]. This would explain
why proximalisation of the input also works.

The DRIL procedure is the most reported albeit all retrospective studies (refer to Table 1) [3, 9, 11-
13, 24, 28-32]. Comparison across studies is limited due to the incomplete reporting of the severity
of DASS of the included patients. The largest study by Huber at al [28] of 77 patients with
moderate or severe ischaemia. Of these 61 were treated with DRIL and 16 required fistula ligation.
Of the patients who underwent the DRIL procedure, the access retention rate was 100%, symptom
relief 78% of patients and bypass patency rates of 77, 74 and 71% at 1, 3 and 5 years respectively.
These rates are typical for all of the DRIL studies (refer to Table 1) with lower success rates being
associated with more severe cases of DASS.

Where reported, patient survival following intervention is generally poor [12, 28, 30, 33] reflecting
the overall poor outcomes for patients affected by DASS associated with a high prevalence of
comorbidities.

4. Studies reporting results of banding to reduce the flow through the fistula are generally limited to
small retrospective reviews [9, 11, 13, 15, 16, 24, 34-39]. The prime problem associated with
banding is the inability to regulate access flow to improve perfusion of the hand while reducing the
risk of thrombosis. As a consequence, banding is often associated with lower success rates in
terms of both symptom control and maintenance of the access. A number of strategies have been
used to attempt to get the balance correct:

a. Using a photoplethysmograph (PPG) on digits to assess degree of banding, however this has
only been reported for 2 patients [16, 39].
b. Use of a digital pulse volume recording, however this has only been reported in a DRIL study
[30].
c. Intra-operative DBI which is lower in those who develop DASS, but not different between
mild/severe steal. Tynan-Cuisinier et al suggest that 50% of patients with asymptomatic DASS
had an intraoperative DBI of <0.6 whereas 25% of patients with asymptomatic DASS had a DBI
<0.45 [19]
d. Using clips.
e. Use of a Goretex cuff [40].
f. Using an intra-vascular balloon to tie the ligature around to get standardised size (4 or 5mm)
[34, 36].

5. The RUDI procedure, which avoids ligation of the artery, has been reported in only 3 studies [9, 41,
42]. These report good success rates in terms of symptom control and maintenance of the access,
however the combined studies include only 15 patients.

6. The PAI procedure, which also avoids ligation of the artery, has been reported in one study of 30
patients with severe DASS [33]. Good success rates in terms of symptom control (84% of patients)
and AV access patency rates (87% at 6 months and 67% at 36 months).

7. Use of tapered grafts – 4mm versus 7mm. 4mm graft shows a 28% reduction in flow at pressure of
100mmHg [43]

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Vascular Access July 2012 Page 4 of 16
SUMMARY OF THE EVIDENCE
There are no randomised controlled trials and only a small number of prospective studies examining the
occurrence, diagnosis and treatment of DASS. Most studies are retrospective reviews of case series
from single centres with limited controls or comparison of interventions.

Can steal be predicted?

Steal is more likely in diabetics, older patients and those with an upper arm fistula or graft, but there are
no clear predictive factors.

Can steal be diagnosed?

Retrograde flow is common in patients with upper extremity AVF’s and AVF’s, however only a small
proportion develop symptomatic DASS. A DBI of <0.6 after formation of a fistula is very likely to be
associated with symptomatic steal.

How should steal be treated?

There are a number of options which should be tailored to the individual patient. An assessment of the
arterial inflow should be performed and arterial stenosis treated. Options then include:
Ligation of AVF
Ligation of distal radial artery if a radio-cephalic fistula
DRIL procedure
PAI procedure
RUDI procedure
Banding of the AV fistula
Use of a tapered graft

WHAT DO THE OTHER GUIDELINES SAY?

Kidney Disease Outcomes Quality Initiative: Guideline 16. [44]
Managing Potential Ischemia in a Limb Bearing an AV Access. All patients, particularly those in
high-risk groups, should be monitored for the development of limb ischemia following AV access
construction.
A. Patients in high-risk groups (diabetic, elderly, those with multiple access attempts in an extremity)
should be monitored closely for the first 24 hours postoperatively. Monitoring should include:
(Opinion)
1. Subjective assessment of complaints, including sensations of coldness, numbness, tingling, and
impairment of motor function (not limited by postoperative pain)
2. Objective assessment of skin temperature, gross sensation, and movement and distal arterial
pulses in comparison to the contralateral side
3. Teaching patients to immediately report any coldness, loss of motion, or significant reduction in
sensation
B. Patients with an established fistula should be assessed monthly. The following are recommended as
part of this assessment: (Opinion)
1. Obtaining an interval history of increased distal coldness or distal pain during dialysis,
decreased sensation, weakness or other reduction in function, or skin changes
2. Confirming any abnormalities by physical examination.
Patients with new findings suggestive of ischemia (A.3 above) should be referred to a vascular
access surgeon emergently. Reduced skin temperature, as an isolated finding, requires follow-
up observation but no emergent intervention. (Opinion)

UK Renal Association: [45]

Guideline 6.3. Treatment of ischemia related to arteriovenous fistulae or grafts. We suggest that the
development of peripheral ischaemia related to arteriovenous fistulae or grafts requires early review by
the vascular access surgeon to allow proactive intervention to prevent the onset of gangrene or need
for amputation. (2B)

Canadian Society of Nephrology: [46]

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Vascular Access July 2012 Page 5 of 16
Guideline 3.5.1. Monitor all patients, particularly those in high-risk groups, for the development of limb
ischemia following AV access construction (opinion).

Europeon Best Practice Guidelines: [47]

Guideline 9.1. Access-induced ischaemia should be detected by clinical investigation and the cause
should be identified by both non-invasive imaging methods and angiography (Evidence level III).
Guideline 9.2. Enhancement of arterial inflow, access flow reduction and/or distal revascularization
procedures are the therapeutic options. When the above methods fail, access ligation should be
considered (Evidence level II).

International Guidelines: No recommendation.

SUGGESTIONS FOR FUTURE RESEARCH

Randomised controlled trials are unlikely to take place, though it would be interesting to compare
proximalisation of inflow and the DRIL procedure.

CONFLICT OF INTEREST
Christine Russell has no relevant financial affiliations that would cause a conflict of interest according to
the conflict of interest statement set down by KHA-CARI.

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Vascular Access July 2012 Page 6 of 16
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APPENDICES
Table 1. Characteristics of included studies

Study ID N Study design Participants Procedure Follow up Comments and results

Gupta (2011) [9] 114 Retrospective All patients who Ligation (n=27) Not stated Risk factors for DASS: Female gender (P=0.040); tobacco use (P=0.048);
(DASS) review, underwent corrective Banding (n=22) diabetes (P=0.016); Hypertension (P<0.001); peripheral vascular disease
100 case/control procedure for DASS. DRIL (n=21) (P=0.008); CAD (P<0.001).
(control) Controls consecutive Improve inflow Patients with DASS more likely to have upper arm fistula than those without
AV access patients (n=9) steal (P<0.001).
from contemporary time RUDI (n=4) Success rate (resolution of DASS and preservation of AV access):
period. PAI (n=3) o Ligation 0% (100% DASS control).
Revascularisation o Banding 38% (19% fistula thrombosis, 48% persistence of
(n=1) DASS)
o DRIL 80% (90% control of DASS, 10% loss of AV)
o RUDI 100%
o PAI 100%
o Revascularisation 100%
Callaghan (2011) 7 Retrospective All brachiocephalic or RUDI Median 19 DASS symptoms resolved in 100% of patients.
[41] review brachiobasilic AVFs months 3 fistulas (43%) failed.
with Grade 3 DASS (range 7-36)
Miller (2010) [34] 183 Case series Patients with DASS or Banding Mean 11 Incidence of DASS and high flow requiring treatment estimated at around
(114 high flow access. (MILLER) months 6%.
with (range, Technical banding success in 98% of attempts.
DASS) 0.25-37) DASS complete symptoms relief – 89% (first banding), 96% (one or more
bandings).
Band related thrombectomies required in 4.4% of DASS patients.
Primary access patency – 52% at 3 months in DASS patients.
Secondary access patency – 90% at 24 months.
Huber (2008) [28] 61 Retrospective All moderate or severe DRIL Mean 12 Incidence of severe hand access related ischaemia – 6%
review ischaemia (Grade 2 or months 77 patients identified of which 61 treated with DRIL and 16 with access
3). (range, 0- ligation
66) 100% access preservation.
Primary DRIL patency rates
o 1 year - 77±8%
o 3 years - 74±9%
o 5 years - 71±9%
Symptom relief – 78%
Patient survival
o 1 year – 71±6%
o 3 years – 59±7%
o 5 years - 33±9%

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Vascular Access July 2012 Page 10 of 16
Study ID N Study design Participants Procedure Follow up Comments and results
Thermann (2008) 63 Retrospective All patients treated for Conservative Overall incidence of DASS – 5.5%
[35] review DASS. Banding Conservative therapy used for 8 patients with mild symptoms.
PAI Treatment success rate –
o Banding - 100% for patients without lesions, 94% primary
patency at 1 year, early thrombosis in 1 patient.
o Banding - 0% for patients with lesions <1 cm and >1cm.
o PAI - 94% for patients with lesions <1cm (not used for other
patient groups), 65% patency at 18 mths.
Yu (2008) [29] 24 Retrospective All patients undergoing DRIL Median 50 Incidence of significant DASS estimated at 2%.
review intervention for DASS months Demographics
o Female - 58%
o Diabetes – 92%
o Hypertension – 88%
Patency of DRIL - 95%
Maintenance of access – 87%
Symptom control – 96%
Mortality – 58%
Walz (2007) [30] 33 Retrospective All patients undergoing DRIL Average Incidence of DASS requiring DRIL – 5.4%
review intervention for DASS 10.5 months Demographics
o Female – 63.9%
o CAD – 69.4%
o Diabetes – 33.3%
o Hypertension – 88%
o Tobacco use – 60%
DRIL patency
o 6 months – 80%
o 12 months – 51%
Symptoms relief
o Relief range from 100% to 66.7% (necrosis)
o Complete resolution of all symptoms – 66.7%
Symptom development after DRIL
o Range from 5.6% to 0% (necrosis, gangrene)
Patient survival
o 1 year - 70%
o 2 years – 36%
Mwipatayi (2006) 18 Retrospective All patients with clinical DRIL (12) Median 4 Symptom improvement with DRIL
[11] review signs of steal confirmed Ligation (5) months o Resolved - 33.3%.
with PPG. Banding (1) (range 1 to o Improved – 50%
Angioplasty (1) 12 months) o No improvement – 16.7%
All DRILL were patent at follow up.
All ligated patients improved.
Banded patient’s graft thrombosed.

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Vascular Access July 2012 Page 11 of 16
Study ID N Study design Participants Procedure Follow up Comments and results
Goel (2006) [36] 16 Case series All patients with DASS Banding Mean 3 Incidence of DASS requiring intervention estimated at 1.3%
requiring intervention. (MILLER) months Symptom improvement – 100%
(maximum Working access within follow up – 100%
11 months)
Asif (2006) [14] 12 Prospective All patients with DASS Angioplasty Mean 8.3 Incidence of patients with DASS symptoms – 3.2%
case series symptoms. Surgical months Complete arteriography performed.
intervention (range, 3-18 Arterial stenosis identified in 10 patients.
months) Angioplasty performed on 8 and surgical intervention on 4.
Angioplasty – 100% resolution of symptoms and 100% access
preservation.
Surgical intervention – 100% resolution of symptoms, 1 access required
ligation.

Zanow (2006) 30 Prospective All patients with severe PAI Mean 26.1 Incidence of DASS requiring intervention – 3.3%
[33] case series DASS and AVF and months PAI undertaken in 23% of patients with DASS.
AVG flow rates <800 (range, 3-61 Significant improvement in DASS symptoms - 84%
ml/min and <1000 months) Primary patency rates
ml/min respectively. o 6 months - 87±6%
o 12 months – 67±11%
Secondary patency rates
o 12 months – 90±5%
o 24 months - 78±8%
Patient survival
o 12 months - 97±3%
o 36 months - 60±11%
Schneider (2006) 22 (6 Case series Patients with high shunt Banding (T-band) 3 months DASS symptom relief – 5 out of 6 (83%)
[37] with flow treated with T- Primary patency at 3 months – 90%
DASS) band Secondary patency at 3 months – 100%
Schanzer (2006) 15 Case control Consecutive patients NA Mean BDP (30 vs 102 mmHg) and DBI (0.3 vs 0.8) significantly lower in
[20] (DASS) with symptomatic DASS patients (P<0.001).
25 DASS. Mean CDP (85 vs 40 mmHg) was significantly higher in DASS patients
(control) Consecutive patients (P<0.001).
without DASS. BDP threshold 60 mmHg – sens, 100%, spec. 87%
DBI threshold 0.4 – sens 92%, spec.96%.
CDP 80 mmHg increase – sens. 78%, spec. 87%

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Vascular Access July 2012 Page 12 of 16
Study ID N Study design Participants Procedure Follow up Comments and results
Tynan-Cuisner 100 Prospective Consecutive patients NA 12 months DBI threshold 0.6
(2006) [19] cohort receiving new AV o Sensitivity – 94%
access fistulas and o Specificity - 43%
grafts. o PPV – 21%
o NPV – 98%
DBI threshold 0.45
o Sensitivity – 80%
o Specificity - 70%
o PPV – 30%
o NPV – 97%
Minion (2005) 4 Case series Patients with DASS RUDI 4 months Complete symptom relief in 3 of the 4 patients.
[42] Partial symptom relief in 1 patient.
No patency rates or maintenance of access reported.
Sessa (2004) 18 Case series Patients with severe DRIL Mean 16 Complete symptom relief – 73%.
[31] DASS months Significant improvement in symptoms – 27%
(range, 5-48
months)
Davidson (2003) 20 Retrospective All upper limb AVF and NA Overall incidence of DASS – 6.2%.
[10] review AVG patients (n=217) Significant risk factors - univariate
o Diabetes
o AVG vs AVF
o Female vs male
o Proximal procedure
o CAD or CVD
Multivariate analysis
o Diabetes
o Aboriginal race
Lazarides (2003) 28 Retrospective All patients with ―limb DRIL Not stated Estimated incidence of ―limb threatening‖ DASS:
[3] review threatening‖ DASS o Overall – 4.2%
requiring surgical o AVG – 5.2%
correction. o AVF – 3.4%
Time interval from initial access to DASS:
o AVG 2 days (range, 1-30)
o AVF 165 days (range, 60-720), P<0.001
Immediate, significant or complete symptom improvement – 100%
Thrombosis during study period – 25%
Symptom free cumulative patency:
o 1 year – 69%
o 2 years – 54%

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Vascular Access July 2012 Page 13 of 16
Study ID N Study design Participants Procedure Follow up Comments and results
Papasavas 35 Prospective ESRD patients 1.2 months Incidence of DASS – 6 (17%).
(2003) [18] cohort requiring upper median for DBI values
extremity DBI, 12 o DASS – 0.8 (pre) drop to 0.4 (post)
haemodialysis. DBI months for o NonDASS – 0.9 (pre) drop to 0.7 (post)
measured DASS DBI threshold <0.6 immediately post surgery (i.e. same day)
preoperatively, symptoms. o Sensitivity – 100%
immediately after o Specificity – 76%
surgery and at follow- o PPV – 46%
up.
Valentine (2002) 72 Prospective Haemodialysis patients PTA Not stated Incidence of DASS 19%
[13] cohort with brachial artery DRIL DASS developed in 50% of AVFs and 13% of AVGs (P<0.001)
fistulas and grafts. Banding DASS patients compared to non DASS had a higher proportion:
Ligation o CAD – P=0.005
o AVF – P=0.009

Knox (2002) [12] 52 Retrospective All patients who DRIL Mean 16 DASS incidence
review underwent DRIL months o Overall - 4.6%.
procedure. (range, 1-67 o Female – 6.5%.
months) o Male – 2.8%.
DASS symptom alleviation – 90%.
Access ligation was required in 3 patients (6%).
Primary patency of DRIL
o 12 months - 86%
o 48 months - 80%
Patient survival
o 12 months - 86%
o 48 months - 56%
Goldfeld (2000) 18 Prospective Patients scheduled for NA 2-4 weeks Six (33%) of patients had hand symptoms within 6 weeks of surgery.
[22] cohort upper extremity 6 months Reverse flow observed in 8 (44%) of patients. Only one symptomatic
proximal arteriovenous patient had reverse flow.
fistulas. There was no statistical correlation between occurrence of symptoms and
absolute peak systolic velocity or the magnitude of the decrease in peak
systolic velocity after surgery.

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Vascular Access July 2012 Page 14 of 16
Study ID N Study design Participants Procedure Follow up Comments and results
Goff (2000) [17] 31 1. Patients with DASS NA Not stated DBI values - retrospective
(DASS) Retrospective requiring surgical o Control – 0.71±0.23 vs 0.91±0.21 (AVF occluded)
24 review. intervention. o DASS – 0.34±0.23 vs 0.78±0.21 (AVF occluded)
(control) Control group – random DBI values – prospective (DASS incidence n=6, 5.5%)
109 2. Prospective sample without DASS. o Asymptomatic – 0.74±0.26 vs 1.01±0.23 (AVF occluded)
(prospe Both groups had o DASS – 0.44±0.13 vs 0.95±0.24 (AVF occluded)
ctive) undergone Threshold DBI value of 0.6:
postoperative DBI. o Sensitivity – 100%
Prospective study – o Specificity – 59%
patients undergoing o PPV – 18%
AVFsurgery. o NPV – 100%

Morsy (1998) [15] 15 Retrospective All patients diagnosed Conservative Not stated Incidence of DASS
review with DASS Banding o 4.3% AVG
o 1.8% AVF
Clinical characteristics
o Diabetes – 66.4%
o Chronic hypertension – 80%
o Peripheral arterial disease – 93.3%
o Coronary artery disease – 53.3%
DeCaprio (1997) 18 Retrospective All patients with Banding (n=11) Not stated DASS incidence - 1.8%
[38] review symptomatic DASS. Symptoms resolved in 10 of 11 patients.
Graft patency after 1 week was maintained in only 1 patient.
Berman (1996) 21 Retrospective All patients who DRIL Mean 8 Incidence of DASS requiring DRIL – 2%
[32] review underwent DRIL months Patient mortality over follow up – 29%
procedure for DASS (range 1 to Patency rate
31 months) o DRILL 18 months – 100%
o Access 18 months – 94%
Separately report on 29 patients subject to banding of which successful
treatment of DASS and maintenance of the access was achieved in 15
(52%)
Haimov (1996) 34 Retrospective Patients with severe Banding Banding – 4 patients
[24] review DASS. DRIL o 3 grafts thrombosed within 3 months
Ligation o 1 – open access at 1 month with partial symptom relief.
Ligation – 23 patients
o DASS improvement after surgery – 100%
o Complete resolution of DASS – 83%
o AVF patency 73% (1 year), 45.5% (2 years)
o Bypass patency 95.6% (1 and 2 years)

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Vascular Access July 2012 Page 15 of 16
Study ID N Study design Participants Procedure Follow up Comments and results
Odland (1991) 27 Retrospective All patients diagnosed Banding 18 months Incidence of DASS
[16] review with DASS o Overall – 5.1%.
o Radiocephalic – 1.1%
o Forearm loop arteriovenous grafts – 7.0%
o Proximal arteriovenous loop grafts – 8.6%
Fistula ligation used in 9 patients with severe DASS.
Intraoperative PPG was used to guide the degree of narrowing to achieve a
digital blood pressure of 50 mm Hg.
DASS symptoms resolved in all 16 patients banded.
Graft patency
o 6 months - 62.5%
o 12 months - 38.5%
Mattson (1987) 2 Case report Patients with DASS Banding Not stated Used PPG to guide degree of banding.
[39] Effective symptom control and lasting access (qualitative reporting only).
Duncan (1986) 24 Cross Haemodialysis patients NA NA A radial steal was indicated by an increase in the thumb/brachial ratio from
[21] sectional 0.61 to 0.85 (P<0.001) in 21 of 24 fistulas.
Only 1 patient had DASS symptoms.

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