Arterial steal syndrome: a modest proposal for an old paradigm.

BACKGROUND Access ligation has been considered to be the treatment for patients presenting with arterial steal syndrome by many nephrologists. We report results of a prospective study using comprehensive arteriography coupled with percutaneous transluminal balloon angioplasty (PTA) or surgical intervention to evaluate and manage steal syndrome. METHODS Twelve consecutive patients referred for symptoms of steal syndrome were examined. Comprehensive arteriography of the extremity to diagnose arterial stenoses and delineate anatomy was performed by advancing a diagnostic catheter into the subclavian artery. Findings of arteriography and degrees of stenosis before and after PTA also were documented. Resolution of symptoms after PTA and surgical interventions, as well as complications, were recorded. RESULTS Angiography showed arterial stenotic lesions in 10 of 12 patients (83%). The degree of stenosis was 66% +/- 14% (SD). Eight patients (80%) with stenotic lesions underwent PTA successfully. The degree of stenosis after PTA was 13% +/- 10%. The remaining 2 patients were not considered candidates for PTA and were referred to surgery with arteriography images. One patient underwent ligation and the other patient required an axillary loop fistula using the same outflow vein. The 2 patients without stenoses showed excessive steal through the anastomosis and underwent lengthening procedures by insertion of a vein segment. All 12 patients are symptom free with a mean follow-up of 8.3 +/- 4 months, and 11 of 12 patients (92%) are dialyzing using the same access. There were no procedure-related complications. CONCLUSION We suggest that complete imaging of the arterial circulation of the extremity be considered in patients presenting with symptoms of steal syndrome to properly assess the arterial anatomy and develop a treatment strategy.