Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis

Background: Hand ischemia resulting from arterial steal is a serious complication in patients undergoing hemodialysis access, but specific risk factors for steal remain in dispute. The purpose of this study was to determine whether plethysmographically derived finger pressures (FPs) or digital-brachial indices (DBIs) are predictive of symptomatic arterial steal. Methods: We prospectively studied 72 patients (37 men, 35 women; mean age, 57 ± 10 years) who were undergoing brachial artery-based hemodialysis access. All patients had complete pre- and postoperative hand examinations and FP determinations. Surgeons were blinded to preoperative FP results. Results: Prosthetic graft was used in 60 patients (6-mm polytetrafluoroethylene [PTFE] in 50, tapered PTFE in 10), and brachial-based arteriovenous fistulas were created in 12. Fourteen (19%) patients developed arterial steal symptoms. The mean preoperative FP was significantly lower in steal patients than in those without steal (131 ± 27 vs 151 ± 31 mm Hg, P < .03). Nine (64%) of the patients with steal had DBIs <1.0, compared to 18 (31%) of the patients without steal (P = .02). However, there was no absolute FP or DBI threshold below which steal was inevitable. The occurrence of steal was attributed to proximal arterial stenoses in seven, to distal arterial disease in five, and was unknown in two. When comparing the 14 patients who developed steal to the 58 who did not, we noted that a higher proportion of steal patients had coronary artery disease (57% vs 17%, P = .005). Steal was more likely to develop in patients with arteriovenous fistulas than in patients with prosthetic grafts (43% vs 14%, P = .009). There were no significant differences in demographic factors, atherosclerotic risks (diabetes, smoking, hypertension, dyslipidemia), prevalence of peripheral vascular disease, cerebrovascular disease, shunt location, tapered vs straight graft, or number of prior grafts placed. Conclusions: These data indicate that preoperative FPs are lower in patients who develop steal syndrome after hemodialysis access. Patients with preoperative DBIs < 1.0 are more likely to develop steal, but there is no DBI threshold below which steal is inevitable. Steal is more likely in patients undergoing brachial-based arteriovenous fistulas than in those receiving prosthetic grafts.