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Steal Syndrome Complicating Hemodialysis Fistula:Its Risk Factors and the Relationship with the Change of Artery’s Hemodynamic

Author: WangZiQiang
Tutor: WangBaoXing
School: Hebei Medical University
Course: Internal Medicine
Keywords: Arteriovenous fistula End-to-side anastomosis stealsyndrome Risk factors hemodynamics Arterial remodeling
CLC: R651.1
Type: Master's thesis
Year: 2012
Downloads: 30
Quote: 0
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Abstract


Objective:Steal syndrome (SS)caused by hemodialysis fistula is aClinical Ischemic changes symptoms syndrome.The fistula leads to localhemodynamic changes and blood flows directly into a vein not through theblood capillary.The result is that the blood to distal limb reduce and it causesthe ischemic changes.The symptoms often appeare in one monthpostoperative,such as cool,pale,numb,pain and so on.The syndrome iscommon seen in the end to side anastomosis and side to side anastomosisfistula.The reason mainly include high flow and artery diseases. SS is a moreserious complication related to the fistula.The more severe could lead toamputation or fingers truncation.Hoek have recorded that the incidence couldbe as high as38%.The foreign researchers discovered that the incidence wasrelated to the race. At present there is few article refer to the incidence andrisk factors of SS inland.Arterial remodeling can be subdivided into acute remodeling andstructural remodeling caused by the fistula. The course with mild stealsymptoms is self-limited. As the artery remodeling, symptoms graduallyalleviate and even disappear.We speculate that the artery remodeling coursepostoperation may be important in the occurrence and development process ofsteal syndrome. Hand pumping blood depends on the brachial artery and theirbranch radial and unlar artery.So it is same to research the relationshipbetween steal syndrome and the artery hemodynamics changes with therelationship between the steal syndrome and the artery remodeling. With thecolor doppler flow imaging (CDFI) development, it has become a quantitativemonitoring method in hemodynamic changes. It has such advantages asnoninvasive, economy and it is often as the preferred method in thedetermination of blood flow and monitoring pathways in fistula morphological change course.It has applied to the study of steal syndrome.In this study we observed the patients who’s fistula meet the criteria,andcollect the clinical data of this study related. All the patients were scheduledfor autogenous radial-cephalic wrist fistula.We observed the incidence of stealsyndrome related to the fistula,and Explore the risk factors.We evaluated thepatients with color Doppler ultrasound examination before and after fistulasurgical procedures,and we monitored the hemodynamic changes of upperlimb artery in this follow-up study.Preliminarily we explore the incidene ofsteal phenomenon and to study the relationship between the occur of stealsyndrome and the remodeling processes of upper limb artery system beforeand after the surgical procedures.The aim of this prospective study is toprovide the theory basis for the future research of the hemodynamic changescaused by the fistula in hand,upper limb and even the whole body.At the sametime this study is to provide certain theoretical foundation for clinicaltreatment of steal syndrome.Methods:Patients who were follow-up in our nephrology department andreferred to vascular surgery department for radio-cephalic end-to-sideanastomosis fistula creation between October2010and October2011wereincluded in the study.To avoid operating skills bias,all surgical procedureswere performed by the same experienced nephrology doctor(LihongZhang).All study participants gave informed consent. General informationsuch as Sex, Age, Diabetes mellitus, Artery disease, Smoking; Biochemicalmaterial such as albumin, blood creatinine, hemoglobin, hematokrit wererecorded from patient files. We also record the ultrasonic monitoring databefore surgery,such as the diameter of brachial artery, radial artery, ulnarartery,and measure radial incision length intraoperative.We monitored thediameter, resistance index, peak systolic velocity, blood flow of the brachialartery, radial artery, ulnar artery with ultrasound,and record the distal radialflow direction and frequency spectrum. The existing reverse flow that suggeststhe presence of steal phenomenon. The patients were divided into steal groupand no steal group according to whether the steal syndrome appeared.The definition of steal used was the development of cool,pale, numbness,pain,muscle atrophy,ulcers,necrosis distal to the fistula site. In order to reduce theerror, each parameter measured3times,and take the average.In this study webuild artery acute remodeling model with each artery system changes1daypreoperative and postoperative,the change of different time pointspostoperative were as the artery chronic remodeling model. The SPSS17.0statistical software for statistical data was processed.Results:1. Preoperative a total of37cases were included into research, male22cases, female15cases, the average age of53.14±14.61years old. There weresteal symptoms in11patients (29.7%) and no steal26cases. The radialincision length are8mm approximately,and compared between the twogroups, p=0.192, which do not have significant differences.So we caneliminate the probability of steal syndrome caused by excessive blood.In thisstudy there were32cases completing the whole observer,17were male,female15cases. We eliminate5cases in analysis of the relationship betweenthe arterial remodeling who were unable to finish the outpatient serviceultrasound review.2. In the postoperative follow-up period we observed that distal radialflow direction and spectrum for the reverse direction included29patients,two-way flow direction3cases.That was to say all the patients were stealphenomenon.3. A univariate analysis show the result that age(OR=1.056,95%CI0.993~1.124,p=0.083),diabetes mellitus(OR=4.267,95%CI0.911~19.988, p=0.066),albumin (OR=0.830,95%CI0.690~0.999,p=0.048),creatinine(OR=1.010,95%CI0.994~1.000,0.069)was foundto be Statistics Significance.These were the risk factors to stealsyndrome.Multivariate analysis was performed age (OR=1.071,95%CI1.005~1.140,p=0.034),albumin(OR=0.768,95%CI0.607~0.971,p=0.027)was found to be Statistics Significance.4. The steal symptom change process:11patients (29.7%) suffered steal syndrome. Among them,10cases were relieved in four weeks postoperativefollow-up,and1was recovery after half year.5. On the whole,preoperation the diameter between radial artery andulnar artery were compared,19patients (51.3%) were radial in dominant.Inthe blood flow there were21cases radial in dominant.All the blood flowparameters of BA, RA and UA were sharp change in postoperation.Thediameter, blood flow, peak systolic velocity are increased dramatically andresistance index were sharply lower(P is less than0.05). Postoperative1to4weeks the artery diameter and blood flow had a growing trend and among1weeks vary considerably.The parameters compared with1days’,in1week itchanged greatly, p<0.05.They were found to be Statistics Significance.After1week, the parameters change more slowly.Compared among1week,2week,and4week,p were More than0.05. They were not found to be StatisticsSignificance.6. The parameters preoperation compared between two groups,p>0.05,They were not found to be Statistics Significance.It was to say that the arteriesbase value was not statistically different between two groups. The growth ofdiameter and blood flow between one day preoperation and postoperationcompared in two groups, p<0.05, They were found to be StatisticsSignificance.7. The diameter and blood flow of arteries in1d,1w,2w,4wpostoperation were compared among different time points of two groups,p>0.05, they were not found to be Statistics Significance.In different timepoints, two groups were compared as p>0.05, they were also not found to beStatistics Significance.8. No steal group was higher than the steal group in diameter and bloodflow of radial artery and ulnar artery postoperation, but compared betweentwo groups was p>0.05, there were not Statistics Significance.The diameterand blood flow of radial compared between two groups were not StatisticsSignificance in different time points.But from the picture we can observed thatthe diameter and blood flow of ulnar artery in two groups were trend to the same point in4w postoperation.Conclusion:1. The patients who are old with poor nutrition (lower albumin) acquirethe radio-cephalic end-to-side anastomosis fistula operation.They arevulnerable to suffer steal syndrome in the process of fistula mature.2. In this study we observe that all of the BA, RA and UA are remodelingafter the operation.It shows diameter expansion, increased blood flow, reducedblood flow resistance. The diameter and blood flow changes greatly in the firstweek after the operation.It becomes more stable after one week. So we couldpreliminary speculate that the flow of fistula increases mainly in the firstweek,and then it becomes more stable.3. In this study we find that the artery is poorer reaction to the actuehemodynamic changes in the patients who suffer steal syndrome.But in thechronic remodeling model,the two groups are not found to be significantlydifferent.4. In the study all the patients suffer steal phenomenon.It is to say that theflow of the fistula can be divided into two parts. one is supplied by the radialartery,and the other is supplied by ulnar artery through the palm arcade.Theblood to hand is no longer supplied by the radial artery.It is to say that theoccurence of steal syndrome is closely related to the remodeling of ulnarartery.

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