The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome
2009; Elsevier BV; Volume: 77; Issue: 4 Linguagem: Inglês
10.1038/ki.2009.461
ISSN1523-1755
AutoresGregg Miller, Naveen Goel, Alexander Friedman, Aleksandr Khariton, Manish C. Jotwani, Yevgeny Savransky, Konstantin Khariton, William P. Arnold, Dean C. Preddie,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoWe evaluated the efficacy of the Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) banding procedure in treating dialysis-associated steal syndrome or high-flow access problems. A retrospective analysis was conducted, evaluating banding of 183 patients of which 114 presented with hand ischemia (Steal) and 69 with clinical manifestations of pathologic high access flow such as congestive heart failure. Patients were assessed for technical success and symptomatic improvement, primary and secondary access patency, and primary band patency. Overall, 183 patients underwent a combined 229 bandings with technical success achieved in 225. Complete symptomatic relief (clinical success) was attained in 109 Steal patients and in all high-flow patients. The average follow-up time was 11 months with a 6-month primary band patency of 75 and 85% for Steal and high-flow patients, respectively. At 24 months the secondary access patency was 90% and the thrombotic event rates for upper-arm fistulas, forearm fistulas, and grafts were 0.21, 0.10, and 0.92 per access-year, respectively. Hence, the minimally invasive MILLER procedure appears to be an effective and durable option for treating dialysis access-related steal syndrome and high-flow-associated symptoms. We evaluated the efficacy of the Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) banding procedure in treating dialysis-associated steal syndrome or high-flow access problems. A retrospective analysis was conducted, evaluating banding of 183 patients of which 114 presented with hand ischemia (Steal) and 69 with clinical manifestations of pathologic high access flow such as congestive heart failure. Patients were assessed for technical success and symptomatic improvement, primary and secondary access patency, and primary band patency. Overall, 183 patients underwent a combined 229 bandings with technical success achieved in 225. Complete symptomatic relief (clinical success) was attained in 109 Steal patients and in all high-flow patients. The average follow-up time was 11 months with a 6-month primary band patency of 75 and 85% for Steal and high-flow patients, respectively. At 24 months the secondary access patency was 90% and the thrombotic event rates for upper-arm fistulas, forearm fistulas, and grafts were 0.21, 0.10, and 0.92 per access-year, respectively. Hence, the minimally invasive MILLER procedure appears to be an effective and durable option for treating dialysis access-related steal syndrome and high-flow-associated symptoms. On the creation of a hemodialysis access, a low-resistance venous pathway is connected to the arterial circuit. This creates the potential for several problems, which cover a spectrum of disease from dialysis-associated steal syndrome (Steal) to high-output cardiac overload. The ideal access functions with just enough pressure and flow to prevent thrombosis while maximizing hemodialysis efficiency. The range of blood flow within a typical dialysis access can be divided into low (<600 ml/min), normal (600–1500 ml/min), and high (1500–4000 ml/min) categories.1Bourquelot P. Stolba J. Surgery of vascular access for hemodialysis and central venous stenosis.Nephrologie. 2001; 22: 491-494PubMed Google Scholar However, the range of flow in the access has very little correlation with patient symptoms. A low-flow access ( 65 years) and diabetics were not significantly different from the total cohort (χ2=2.5, P=0.11 and χ2=0.19, P=0.66, respectively). The secondary access patency of the 16 patients from the initial MILLER banding reports19Goel N. Miller G.A. Jotwani M.C. et al.Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome.Kidney Int. 2006; 70: 765-770Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar was 77% at 36 months.Figure 3Secondary access patency for dialysis-associated steal syndrome (Steal) and High Flow patients (24 months).View Large Image Figure ViewerDownload (PPT) Three of our graft banding patients had previously undergone DRIL procedures and received 3 mm diameter bandings to augment effectiveness of the bypass. Five of our fistula banding patients had previously undergone traditional open surgical banding procedures and were rebanded using the MILLER technique. In a subset of patients, flow and pressure measurements were obtained. The average initial flow in Steal (n=8) and High Flow (n=12) patients was 2034 and 2629 ml/min, and the average flow reduction was 1046 (50%) and 1354 ml/min (52%), respectively. In Steal and High Flow patients (n=4), the average initial intra-access pressure was 45 mmHg and the average pressure reduction was 23.5 mmHg (51.4%). A total of eight Steal patients and two High Flow patients died during the follow-up period; however, their deaths were unrelated to the procedure and their accesses were patent at the time of death. Six patients had kidney transplants during follow-up. Major complications occurred in two patients with AVGs and one patient with an AVF. These patients developed cellulitis, which spread from our transverse incision to the AV access, resulting in access ligation and graft removal within 14 days. The protocol was then modified to include antibiotic prophylaxis. In addition, the dissection technique was modified to consist of two lateral incisions instead of one transverse incision (with full exposure of the access).19Goel N. Miller G.A. Jotwani M.C. et al.Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome.Kidney Int. 2006; 70: 765-770Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar No infections occurred in the 179 subsequent procedures. Minor complications included three cases of access (two AVFs and one AVG) bleeding during the procedure. These were treated with manual compression of the injured area until bleeding subsided, and did not result in delayed hemodialysis treatments. No patients required hospitalization or open surgical repair to control bleeding. The introduction of a high-resistance band should correct steal and high flow in vascular accesses by diminishing access flow, and restoring sufficient distal arterial flow and perfusion. In accesses with normal to high flow, banding is appropriate but requires the operator to precisely control the diameter of the band.14Lebow M.H. Cassada D.C. Freeman M.B. et al.Preemptive distal revascularization-interval ligation to prevent ischemic steal after hemodialysis access surgery.J Surg Educ. 2007; 64: 171-173Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 15Lazarides M.K. Staramos D.N. Panagopoulos G.N. et al.Indications for surgical treatment of angioaccess-induced arterial ‘steal.J Am Coll Surg. 1998; 187: 422-426Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 20Zanow J. Petzold K. Petzold M. et al.Flow reduction in high-flow arteriovenous access using intraoperative flow monitoring.J Vasc Surg. 2006; 44: 1273-1278Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Thermodilution-based flow measures are inaccurate when access flow reduction is used as a surrogate for distal arterial flow enhancement. Techniques such as finger plethysmography and the digital-brachial index21Odland M.D. Kelly P.H. Ney A.L. et al.Management of dialysis-associated steal syndrome complicating upper extremity arteriovenous fistulas: use of intraoperative digital photoplethysmography.Surgery. 1991; 110 (discussion 669–670): 664-669PubMed Google Scholar,22Schanzer H. Eisenberg D. Management of steal syndrome resulting from dialysis access.Semin Vasc Surg. 2004; 17: 45-49Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar are measures of distal perfusion, but their utility is severely limited intra-operatively by changes in blood pressure, heart rate, and cardiac output experienced during administration of general anesthesia. When used as independent measures to adjust band size, they have suboptimal outcomes.21Odland M.D. Kelly P.H. Ney A.L. et al.Management of dialysis-associated steal syndrome complicating upper extremity arteriovenous fistulas: use of intraoperative digital photoplethysmography.Surgery. 1991; 110 (discussion 669–670): 664-669PubMed Google Scholar Combined, these techniques have yielded acceptable outcomes;20Zanow J. Petzold K. Petzold M. et al.Flow reduction in high-flow arteriovenous access using intraoperative flow monitoring.J Vasc Surg. 2006; 44: 1273-1278Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar,23van Hoek F. Scheltinga M. Luirink M. et al.Banding of hemodialysis access to treat hand ischemia or cardiac overload.Semin Dial. 2009; 22: 204-208Crossref PubMed Scopus (39) Google Scholar however, they cannot be standardized because of the influence of innumerable confounding variables and such results may not be easily reproducible by less experienced operators, using the same parameters. The use of an intraluminal balloon as a sizing dowel is likely to prove useful not only for the minimally invasive MILLER procedure but also during open surgical banding procedures. The MILLER banding technique modulates band size with great precision, eliminating the need for complex flow and perfusion measurements. No expensive equipment or advanced measurement devices were needed for any patients. Using the sizing nomogram (Figure 4, Murray et al.24Murray B.M. Rajczak S. Herman A. et al.Effect of surgical banding of a high-flow fistula on access flow and cardiac output: intraoperative and long-term measurements.Am J Kidney Dis. 2004; 44: 1090-1096Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar), the decision-making process is simplified to the creation of a band that results in a 60–80% reduction in lumen diameter. Therefore, 7-mm-diameter grafts were banded to 3 mm, and 20-mm-diameter upper-arm fistulas were banded to 5 mm. To overcome high distal arterial resistances, some forearm fistulas were banded to as little as 2.5 mm. In cases where the ligature size was inadequate, it was adjusted incrementally, as accesses were rebanded to a smaller size. In cases of access thrombosis, the bands were stretched, or even broken with a larger diameter angioplasty balloon. No significant vessel wall injury occurred after band breaking, as verified by follow-up angiograms. Banding physiology is best explained by Poiseuille's Law, which states that fluid flow (Q) is proportional to radius (r), pressure across a gradient (ΔP, for example, arterial pressure-central venous pressure) and inversely proportional to resistances, length (L), and viscosity (η): Q=(ΔPπr4)/(8ηL). The MILLER banding technique decreases flow by decreasing the radius at a specific point and, as a result, access flow (Qaccess) and pressure is directly sacrificed to increase distal arterial flow (Qdistal) and pressure. Therefore, in accesses with low-flow (low Qaccess) steal, further flow reduction could lead to access thrombosis. These patients may benefit most from revasculatization procedures such as DRIL17Schanzer H. Schwartz M. Harrington E. et al.Treatment of ischemia due to ‘steal’ by arteriovenous fistula with distal artery ligation and revascularization.J Vasc Surg. 1988; 7: 770-773Abstract Full Text PDF PubMed Scopus (165) Google Scholar and PAI,18Zanow J. Kruger U. Scholz H. Proximalization of the arterial inflow: a new technique to treat access-related ischemia.J Vasc Surg. 2006; 43 (discussion 1221): 1216-1221Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar which enhance total extremity flow and therefore enhance both Qdistal and Qaccess. In the first patients we treated, complete symptomatic relief was less important than avoidance of thrombotic events; therefore, we conservatively used larger intraluminal balloons (with a target of 60% lumen reduction) and then repeated the procedure in 4 weeks if residual symptoms persisted. With experience, estimation of initial band size improved, as we came to understand that clinical success could be more readily achieved (without inducing thrombosis) with a lumen reduction of ∼75%. Flow measurements during the procedure have further improved the accuracy of our selection of initial band size. In 9% of patients, rebandings were performed to enhance clinical efficacy. The majority of patients who required multiple bandings were Steal patients with low-normal blood pressure and High Flow patients with severe hypertension, as extremes of blood pressure made predicting the appropriate band size more difficult. During a rebanding, the resistance of a single band was augmented by placement of additional bands to create a segment of resistance rather than a focus of resistance. Such an increase in access resistance was necessary to overcome the high flow of a hypertrophic proximal artery in High Flow patients. Steal patients who required additional bandings ultimately achieved clinical success as resistance in the access increased beyond the peripheral resistance associated with arterial occlusions. When these arteries are occluded, the maximum Qdistal is decreased, and access flow must be reduced to a much greater extent in order to generate the flow and pressure necessary to divert a sufficient amount of blood to collateral arteries. In two Steal patients who required access ligation, the occlusion of both forearm arteries made adequate Qdistal impossible to achieve without a reduction of Qaccess that would make the access unusable. Access interventions have historically been performed at rates as high as 5.3 per access-year for fistulas and 3.7 per access-year for grafts to decrease thrombotic events.25Sands J.J. Miranda C.L. Prolongation of hemodialysis access survival with elective revision.Clin Nephrol. 1995; 44: 329-333PubMed Google Scholar In our study, procedures were performed at a rate of 2.9 and 3.5 interventions per access-year in Steal and High Flow accesses, respectively. The primary access patency was 56% at 3 months, primarily due to the angioplasty of venous outflow stenoses. Previous studies have obtained thrombosis rates of 1.1 per access-year in grafts25Sands J.J. Miranda C.L. Prolongation of hemodialysis access survival with elective revision.Clin Nephrol. 1995; 44: 329-333PubMed Google Scholar and 0.13–0.57 per access-year in fistulas.25Sands J.J. Miranda C.L. Prolongation of hemodialysis access survival with elective revision.Clin Nephrol. 1995; 44: 329-333PubMed Google Scholar, 26Schwab S.J. Raymond J.R. Saeed M. et al.Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses.Kidney Int. 1989; 36: 707-711Abstract Full Text PDF PubMed Scopus (383) Google Scholar, 27Besarab A. Sullivan K.L. Ross R.P. et al.Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis.Kidney Int. 1995; 47: 1364-1373Abstract Full Text PDF PubMed Scopus (240) Google Scholar Given these results, our thrombosis rates of 0.20 per access-year in fistulas and 0.92 per access-year in grafts are comparable with non-banding studies, suggesting that the MILLER method of banding does not compromise access durability in order to achieve the necessary flow reduction. In our study, secondary access patency remained high after 24 months (90%). By comparison, the largest DRIL study to date (with grafts comprising 60% of accesses) obtained a 90% rate of clinical success (Table 3), with a 6% rate of thrombosis at an average follow-up of 7.4 months.28Knox R.C. Berman S.S. Hughes J.D. et al.Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access.J Vasc Surg. 2002; 36 (discussion 256): 250-255Abstract Full Text PDF PubMed Scopus (153) Google Scholar In that study, as well as others,29Mwipatayi B.P. Bowles T. Balakrishnan S. et al.Ischemic steal syndrome: a case series and review of current management.Curr Surg. 2006; 63: 130-135Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar accesses with persistent Steal were ligated. We propose that the rate of DRIL clinical success can be further augmented through the application of the MILLER banding technique on such clinical failures, as three of our successfully treated banding patients had previously undergone DRIL procedures without complete symptomatic relief.Table 3Review of the literatureStudyProcedureIndicationAccess typePatients (n)Symptom resolution (%)Secondary patency at 12 months (%)Flow reduction (%)Aschwanden et al.35Aschwanden M. Hess P. Labs K.H. et al.Dialysis access-associated steal syndrome: the intraoperative use of duplex ultrasound scan.J Vasc Surg. 2003; 37: 211-213Abstract Full Text Full Text PDF PubMed Scopus (38) Google ScholarBandingStealFistula310010068DeCaprio et al.36DeCaprio J.D. Valentine R.J. Kakish H.B. et al.Steal syndrome complicating hemodialysis access.Cardiovasc Surg. 1997; 5: 648-653Crossref PubMed Scopus (95) Google ScholarBandingStealGraft119110NDMeyer et al.37Meyer F. Muller J.S. Grote R. et al.Fistula banding—success-promoting approach in peripheral steal syndrome.Zentralbl Chir. 2002; 127: 685-688Crossref PubMed Scopus (19) Google ScholarBandingStealFistula7100NDNDMorsy et al.3Morsy A.H. Kulbaski M. Chen C. et al.Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure.J Surg Res. 1998; 74: 8-10Abstract Full Text PDF PubMed Scopus (159) Google ScholarBandingStealFistula and graft66733NDOdland et al.21Odland M.D. Kelly P.H. Ney A.L. et al.Management of dialysis-associated steal syndrome complicating upper extremity arteriovenous fistulas: use of intraoperative digital photoplethysmography.Surgery. 1991; 110 (discussion 669–670): 664-669PubMed Google ScholarBandingStealFistula and graft1610039NDSchneider et al.38Schneider C.G. Gawad K.A. Strate T. et al.T-banding: a technique for flow reduction of a hyperfunctioning arteriovenous fistula.J Vasc Surg. 2006; 43: 402-405Abstract Full Text Full Text PDF PubMed Scopus (29) Goog
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