Learning Center

Module 8: Hand Ischemia: Dialysis Access Steal Syndrome

Dialysis Access Steal Syndrome (DASS), is a potentially devastating complication that occurs in 5-10% of cases when the distal brachial artery is used as inflow, which is g about 10 times that of wrist arteriovenous fistulas (AVFs) using the distal radial artery. Depending on the type and location of arteriovenous (AV) access the risk of severe access-related steal syndrome stage III or IV varies. Following the creation of a femoral access, an even higher incidence of steal syndrome has been reported. Due to the rise in the median ages of incidence and prevalence of hemodialysis patients and due to the growing percentages of diabetics among them, access-related ischemia has become a growing problem. Unrecognized and untreated steal may carry severe morbidity including tissue or limb loss. 

There are three distinct etiologies that may occur alone or in concert: 

  • Blood flow restriction to the hand from arterial occlusive disease proximal or distal to the AV access anastomosis
  • Excess blood flow through the AV access (true steal)
  • Lack of vascular (arterial) adaptation or collateral flow reserve (i.e. atherosclerosis) to the increased flow demand from the AV access

LEARNING OBJECTIVES

  • List and describe three distinct etiologies of the steal syndrome
  • Classify steal by graded severity
  • Verbalize treatment options of the steal syndrome
  • Identify common risk factors for steal
  • List strategies to prevent steal

Method of Participation

To obtain credit, a score of 70% or better on the post-test is required. Please proceed with the activity until you have reviewed module materials, successfully answered all post-test questions, completed the evaluation, and have received a digital copy of your CME certificate. You must participate in the entire activity to receive credit. If you have questions about this CME activity, please contact Complete Conference Management at cme@CCMCME.com.

Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Complete Conference Management and Online CME, Inc.

Complete Conference Management is accredited by the ACCME to provide continuing medical education for physicians.

Physician Assistants

NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

Credit Designation

Complete Conference Management designates this enduring activity for a maximum of 3.0 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

FACULTY 

Ingemar Davidson, MD, PhD, FACS

Dr. Davidson has no relevant financial relationships reported.

Gerald Beathard, MD, PhD

Dr. Beathard has no relevant financial relationships reported.

Bart Dolmatch, MD, FSIR Dr. Dolmatch is a consultant and advisor to Bard, Humacyte, Bluegrass Vascular Tech, Merit Medical and Histosonics.

Nicholas Inston, MD, PhD

Dr. Inston has been an investigator for TVA and Humacyte and an educational consultant for Merit Medical, Gore and SynerMed. 

Behram Kahn, MD

Dr. Kahn has no relevant financial relationships reported study.

John Ross, MD Dr. Ross is a consultant for Bard Peripheral Vascular, WL Gore and Associates, LeMaitre Vascular Inc. and Boston Scientific.

John Swinnen, MD

Dr. Swinnen has no relevant financial relationships reported study

 

SUPPORTING FACULTY

Magdalena Biss-Mierzwińska, MD

Dr. Magdalena Biss-Mierzwińska has no relevant financial relationships reported.

Pierre Bourquelot, MD

Dr. Bourquelot has no relevant financial relationships reported.

Teresa Chuva, MD

Dr. Teresa Chuva has no relevant financial relationships reported.

Maurizio Gallieni, MD

Dr. Gallieni has no relevant financial relationships reported.

Ulf Hedin, MD

Dr. Hedin has no relevant financial relationships reported.

Jackie Pei Ho, MD

Dr Ho has no relevant financial relationships reported.

Jose Ibeas, MD, PhD

Dr. Ibeas has no relevant financial relationships reported.

Aurang Zaib Khawaja MD

Dr Khawaja has no relevant financial relationships reported

Hailei Li, MD, PhD

Dr. Li has no relevant financial relationships reported.

NC Liew, MD

Dr. Liew has no relevant financial relationships reported

Alexandro Mallios, MD

Dr. Mallios is a consultant and advisor to Avenu Medical

Linda Nuth, MD

Dr. Nuth has no relevant financial relationships reported

Kittipan Perkasem, MD

Dr. Perkasem has no relevant financial relationships reported

Ramon Roca Tey, MD, PhD Dr. Roca Tey has no relevant financial relationships reported.

Tobias Steinke, MD

Dr. Steinke is a consultant and advisor to Angiomed Karlsruhe GER, CR Bard Karlsruhe GER, TVA Medical Austin Texas USA.

Martina Tedesco, MS Dr. Tedesco has no relevant financial relationships reported.

 

Staff/Reviewers

Tracey Fernandez, CMP

Ms. Fernandez has no relevant financial relationships reported.

Barbara OBrien, MSN, BSN, RN  Ms. O’Brien has no relevant financial relationships reported.

Comercial Support

This activity is supported by unrestricted educational grants from the following companies: Arrow International, Inc./Teleflex, Lutonix Technology Center/Bard, Boston Scientific Corporation, Le Maitre Vascular, Inc., Medtronic and W.L. Gore

CME Credit hours Earned: 3.0 Hour(s)

Fee: $0.00  - Free

 

Disclosure Policy Statement

In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support, educational programs sponsored by Complete Conference Management must demonstrate balance, independence, objectivity and scientific rigor.  All faculty, authors, editors and planning committee members participating in a CCM-sponsored activity are required to disclose any relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services that are discussed in an educational activity.

Disclosure of Unlabeled Use and Investigational Product

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Complete Conference Management makes every effort to develop CME activities that are scientifically based. This activity is designed for educational purposes. Participants have a responsibility to utilize this information to enhance their professional development to improve patient outcomes. Conclusions drawn by the participants should be derived from careful consideration of all available scientific information. The participant should use his/her clinical judgment, knowledge, experience and diagnostic decision-making before applying any information, whether provided here or by others, for any professional use.

Required Hardware / Software

A computer with an internet connection. Internet Browser: Internet Explorer 7.x or higher, Firefox 4.x or higher, Safari 2.x or higher, or any other W3C standards compliant browser. Other additional software may be required such as PowerPoint or Adobe Acrobat Reader.

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Key:

Complete
Failed
Available
Locked
Pre-test
15 Questions  |  1 attempt  |  0/15 points to pass
15 Questions  |  1 attempt  |  0/15 points to pass
DIALYSIS ACCESS STEAL SYNDROME INTRODUCTION
PATHOPHYSIOLOGY OF DIALYSIS ACCESS STEAL SYNDROME (DASS)
EVALUATION AND TESTING
PHYSICAL EXAMINATION AND TESTING FOR DASS
CLINICAL PRESENTATION OF STEAL
DASS TREATMENT OPTIONS OF STEAL RELATED TO SEVERITY OF SYMPTOMS
OBSERVATION – EVALUATION of STEAL
DRAL - DISTAL RADIAL ARTERY LIGATION
DRIL - DISTAL REVASCULARIZATION INTERVAL LIGATION
PAI - PROXIMAL ARTERIAL INFLOW
RUDI - REVISION USING DISTAL INFLOW
PREVENTION OF DASS
Additional Reading: Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies
Open to download resource.
Open to download resource.
Additional Reading: Hand Ischemia Associated With Dialysis Vascular Access: An Individualized Access Flow-based Approach to Therapy
Open to download resource.
Open to download resource.
Additional Reading: Arteriovenous access ischemic steal (AVAIS) in haemodialysis: a consensus from the Charing Cross Vascular Access Masterclass 2016
Open to download resource.
Open to download resource.
Additional Reading: The DRIL procedure for arteriovenous access ischemic steal: A controversial approach
Open to download resource.
Open to download resource.
Additional Reading: ASDIN white paper: Assessment and management of hemodialysis access- induced distal ischemia by interventional nephrologists
Open to download resource.
Open to download resource.
Post-test
15 Questions  |  Unlimited attempts  |  10/15 points to pass
15 Questions  |  Unlimited attempts  |  10/15 points to pass
Survey
5 Questions
Certificate
Up to 3.00 medical credits available  |  Certificate available
Up to 3.00 medical credits available  |  Certificate available