• Users Online: 344
  • Print this page
  • Email this page

Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 91-92

Access-related hand ischemia in a child with brachiocephalic arteriovenous fistula

Division of Pediatric Nephrology (Unit 2), Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission13-May-2021
Date of Decision30-Jun-2021
Date of Acceptance20-Jul-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Indira Agarwal
Division of Pediatric Nephrology (Unit 2), Department of Child Health, 5th Floor, ISSCC Building, Christian Medical College, Vellore - 632 004, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajpn.ajpn_21_21

Rights and Permissions

How to cite this article:
Shirke PP, Veetil DR, Mathew G, Agarwal I. Access-related hand ischemia in a child with brachiocephalic arteriovenous fistula. Asian J Pediatr Nephrol 2021;4:91-2

How to cite this URL:
Shirke PP, Veetil DR, Mathew G, Agarwal I. Access-related hand ischemia in a child with brachiocephalic arteriovenous fistula. Asian J Pediatr Nephrol [serial online] 2021 [cited 2023 May 27];4:91-2. Available from: https://www.ajpn-online.org/text.asp?2021/4/2/91/334032


A 10-year-old boy presented with a 4-month history of progressive wasting of left hand and forearm. The child had been initiated on hemodialysis through a left brachiocephalic fistula 10 months previously. The child had progressed to end-stage kidney disease within 6 months of presentation with biopsy-proven focal segmental glomerulosclerosis. At first use, the fistula was well functioning without any issues related to patency or blood flow during hemodialysis sessions. Ten months later, the child noticed symptoms of occasional numbness, poor grip, and relative coolness of the left hand as compared to the right. Fistula examination revealed a healthy fistula scar with 3 cm aneurysmal swelling in the left cubital fossa and thrill. Both the radial and ulnar pulses of the left upper limb were feeble and of low volume. Examination of the forearm revealed wasting of muscles of thenar and hypothenar eminences of the left hand, and left forearm [Figure 1]. There was a discrepancy in the palm size; the length and breadth on the left palm were lower than the right palm by 10 mm and 5 mm, respectively. A clinical diagnosis of ischemic steal syndrome secondary to arteriovenous fistula was made. Since the patient did not return for Doppler ultrasound and further follow-up, the diagnosis could not be confirmed.
Figure 1: Clinical images. (a) Palmar aspects of both hands demonstrating wasting of the thenar and hypothenar eminences of the left hand. (b) Dorsal view revealing visible wasting of the left hand. (c) Anterior view of left cubital fossa showing ~3 cm aneurysmal dilatation of the brachiocephalic arteriovenous fistula

Click here to view

Steal syndrome, characterized by ischemic symptoms of pain and paresthesia, occurs in <2% of radiocephalic fistulae and 5%–10% of brachiocephalic fistulae.[1] While this condition is extremely rare in children,[2] additional effect on growth of the affected limb is a risk during growing age, resulting in limb hypoplasia through vascular compromise. Reduced outflow or inflow to the fistula, obstruction,and/or lack of collateral blood supply result in the characteristic symptoms of steal syndrome.[3] Diagnosis depends on clinical examination, and the clinical spectrum of ischemia is classified into four stages based on the severity of signs, including pallor, decreased or absent pulses, sensory or motor neuropathy, nail changes, distal discoloration, and/or ulcers.[4] Mild cases are managed through frequent follow-up evaluation, with special attention to subtle neurologic changes and evidence of muscle wasting. If conservative measures fail, a stenotic lesion in the inflow feeding artery should be ruled out.[5] Additional evaluations that should be considered include digital blood pressure, digital to brachial index, digital plethysmography, transcutaneous oxygen saturation, Doppler ultrasonography, and ultimately, an arteriogram. Definitive management is surgical or endovascular intervention that augments distal blood flow through various banding techniques. As a last resort, AV dialysis access closure should be considered.[1]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

  References Top

Salman L, Asif A. New horizons in dialysis access: Approach to hand ischemia. Adv Chronic Kidney Dis 2020;27:208-13.  Back to cited text no. 1
Wartman SM, Rosen D, Woo K, Gradman WS, Weaver FA, Rowe V. Outcomes with arteriovenous fistulas in a pediatric population. J Vasc Surg 2014;60:170-4.  Back to cited text no. 2
Baer R, McDonald S, Wu R, Mantha M. Reversible advanced ischemic hand atrophy due to arteriovenous fistula steal. Kidney Int 2008;73:1203-4.  Back to cited text no. 3
McArdle DJ, Cottier D, Beasley A. Digital ischaemia secondary to steal syndrome from a brachiocephalic arteriovenous fistula. BMJ Case Rep 2016;2016:bcr2016217323. doi:10.1136/bcr-2016-217323.  Back to cited text no. 4
Beathard GA, Jennings WC, Wasse H, Shenoy S, Hentschel DM, Abreo K, et al. ASDIN white paper: Assessment and management of hemodialysis access-induced distal ischemia by interventional nephrologists. J Vasc Access 2020;21:543-53.  Back to cited text no. 5


  [Figure 1]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Article Figures

 Article Access Statistics
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal