Case Presentation: Our patient is a 65 year old male with history of end stage renal disease on hemodialysis, peripheral arterial disease complicated by bilateral below knee amputations, and type 2 diabetes mellitus admitted with limited flow on his right AV fistula. An IR fistulagram revealed moderate stenosis of the basilic vein outflow, and mild stenoses of the axillary vein and brachiocephalic vein. Angioplasty was performed to 8, 10, and 10 mm. Upon completion, an excellent thrill was palpable, and there was improved venographic appearance. Two days later, he developed right hand pain with ulceration of the right digits. He had a doppler ultrasound which revealed a patent right brachiobasilic AV fistula with tortuosity and velocities as high as 398 cm/s within the brachial artery just after the anastomosis. His right radial and ulnar arteries were patent distally with antegrade flow consistent with dialysis steal syndrome. He then underwent IR angiogram which showed findings consistent with steal phenomenon exacerbated by superimposed forearm and hand atherosclerosis with resultant absence of perfusion to the right index and long fingertips. He underwent ligation of the AV fistula and subsequent amputation of the right index digit due to infection two months later.

Discussion: Dialysis access steal syndrome (DASS), or hemodialysis distal access-induced ischemia (HAIDI) is a complication of arteriovenous (AV) fistulas placed for HD with variable manifestations. The clinical presentation can range from mild symptoms, such as coolness, pallor, mild paresthesia, and pain during HD, or to more severe symptoms such as pain at rest, paralysis, ulceration, and tissue necrosis, which can result in digit or hand amputation. Risk factors include age >60 yo, diabetes mellitus, and presence of other vascular disease (CAD or CVA). Atherosclerotic vascular disease distal to the fistula is a key risk factor for digital gangrene as in this case. Diagnosis can be made based on the clinical history and physical exam through manually compression of the AV access and noting an improvement in the patient’s symptoms. Imaging is required to determine the anatomic cause of the steal with non-invasive imaging preferred. Physiologic tests such as digital waveforms pressures, with and without AV fistula compression, are sensitive for a diagnosis of steal syndrome, while duplex ultrasound can identify the presence of arterial stenosis and/or flow reversal. Treatment is based on the clinical stage and severity of ischemia. For patients who have mild symptoms and do not require intervention, blood pressure should be optimized to avoid hypotension, and a warming glove can be used. Interventions depend on the vascular lesion, ranging from banding to distal revascularization interventions but may include amputation.

Conclusions: Chronic kidney disease is common in the United States (US), with 37 million, or with 1 in 7 adults currently affected. As of 2020, 786,000 US adults have end stage renal disease, with 71% undergoing dialysis, and the prevalence is expected to rise to an estimated 1.3 million dialysis patients by 2030. Hemodialysis (HD) is the primary method of renal replacement therapy thus understanding of complications related to HD and vascular access modalities necessary to perform it is paramount for general internists and hospitalists. DASS occurs in 1-20% of patients with AV fistulas, but is under recognized due to the wide range of symptoms. Early intervention can result in reduced morbidity associated with the disorder.