Case Presentation: A 63-year-old male with end-stage renal disease, on hemodialysis via left arteriovenous fistula for over 10 years, presented with progressively worsening left fifth-digit infection and severe hand pain over the last month. Additional history includes peripheral vascular disease resulting in bilateral above-the-knee amputations and recent right fourth-digit amputation. He was seen outpatient by orthopedics a week prior to admission with the recommendation to monitor symptoms with plans for further amputation. Exam revealed no palpable left radial pulse and diminished range of motion. Left upper extremity computed tomography angiography showed patent contrast runoff to the level of the wrist and a patent upper extremity arteriovenous fistula with mild intimal thickening in the proximal outflow stent. Empiric antibiotic therapy was started for cellulitis. Vascular surgery, orthopedic surgery, and nephrology were consulted. Our team suspected Steal Syndrome but consulting services felt this was unlikely. A fistulogram was ordered to evaluate. It showed marked improvement of arterial opacification with compression of the dialysis fistula confirming arteriovenous fistula steal syndrome leading to 5th digit necrosis and impending necrosis of remaining digits. The fistula was ligated, and the left fifth digit was amputated. After the procedure, the remaining left fingers were warm and well-perfused, and his pain and range of motion greatly improved.

Discussion: Steal syndrome is a rare complication of arteriovenous fistulas with hand ischemia occurring in 4% of patients and less than 1% experiencing distal necrosis. Steal occurs due to preferential flow through a low resistance outflow tract, bypassing higher resistance arterial segments. The presentation of steal is like that of other ischemic conditions such as embolism or vascular disease. These symptoms include non-palpable pulses, cold extremities, and pain. Symptoms may present acutely within a month of creation of the fistula, or chronically, even 20 years after. Unlike vascular disease, steal syndrome is curable and thus should be on the differential in any dialysis patient with hand ischemia, regardless of when the fistula was placed. Dialysis access steal is diagnosed with an arteriogram or duplex Doppler ultrasound. Visualizing increased flow with fistula compression using either modality confirms the diagnosis. Treatment options include ligation, banding, or revascularizing the arteriovenous access.

Conclusions: This vignette outlines a case of dialysis access steal in a patient with a history of multiple prior amputations secondary to peripheral vascular disease. Diagnosis for this patient was delayed given low suspicion and his history of severe vascular disease as the assumed cause of ischemia. Given the risk of significant limb dysfunction or loss, consider a workup for steal syndrome in dialysis patients with hand ischemia, even when the diagnosis seems unlikely.

IMAGE 1: Fistulogram Prior to Compression of Arteriovenous Fistula

IMAGE 2: Fistulogram Post Compression of Arteriovenous Fistula