|Year : 2021 | Volume
| Issue : 2 | Page : 91-92
Access-related hand ischemia in a child with brachiocephalic arteriovenous fistula
Prateek Pramod Shirke, Deepthi R Veetil, Georgie Mathew, Indira Agarwal
Division of Pediatric Nephrology (Unit 2), Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||13-May-2021|
|Date of Decision||30-Jun-2021|
|Date of Acceptance||20-Jul-2021|
|Date of Web Publication||28-Dec-2021|
Division of Pediatric Nephrology (Unit 2), Department of Child Health, 5th Floor, ISSCC Building, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|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 2022 May 28];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. While this condition is extremely rare in children, 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. 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. 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. 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.
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|| |
Salman L, Asif A. New horizons in dialysis access: Approach to hand ischemia. Adv Chronic Kidney Dis 2020;27:208-13.
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.
Baer R, McDonald S, Wu R, Mantha M. Reversible advanced ischemic hand atrophy due to arteriovenous fistula steal. Kidney Int 2008;73:1203-4.
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.
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.