Ischemic disorders of the limb in AVF for chronic hemodialysis

Abstract

Ischemic steal syndrome (ISS) develops from 2 to 20% of cases in patients on chronic hemodialysis with arteriovenous fistula (AVF) or arteriovenous prosthesis (AVP). Moreover, there is a different frequency of ISS development in patients with distal (radiocephalic) AVF and proximal AVF. For radiocephalic fistulas, this index is about 2%. With proximal fistulas, ISO can reach up to 20-25%. The purpose of the study: To conduct an analysis of the clinical course of ischemic syndrome distal to permanent vascular access for people suffering from Stage 5 of Chronic kidney disease with efferent renal replacement therapy. Research materials and methods. The terms of the development of ischemic disorders after the formation of permanent vascular access (PVA) in patients with AVF are from an hour to a week ("acute"), but can appear after a month or more ("chronic") and even after several years. Despite the fact that the severity of "chronic" ischemia is usually moderate, long-term complaints of hypoperfusion can lead to trophic disorders, up to necrosis and gangrene (about 1% of patients). It is also noted that up to 25% of patients have temporary ischemic complications after the formation of AVF and AVP. There is currently no generally accepted ISS classification. In the foreign literature, there are several attempts by different researchers to develop a classification that would be of practical importance for the diagnosis and treatment of ISS. Research results and their discussion. Most of the authors base their practice primarily on the clinical diagnosis of ISS. Instrumental diagnostics has a clarifying character. Taking an anamnesis can reveal risk factors for the development of ISS. To identify complaints, some authors proposed a questionnaire based on the visual analog scale (VAS), in which points are obtained by multiplying the subjective severity of symptoms (from 0 to 10) by their frequency of occurrence (0 – never, 10 – always). A decrease in tactile and temperature sensitivity may be detected during a neurological examination. One of the most severe variants of acute ischemic syndrome is the development of so-called unilateral ischemic neuropathy. Trophic disorders occurring on the limbs containing arteriovenous access (AVA) can also be the result of venous hypertension, which is accompanied by edema. NKF/DOQI 2006 recommendations require the immediate elimination of access when an UIN is detected. However, even in cases where this complication is detected in the shortest possible time, and the fistula is ligated, full regression of symptoms does not occur in all patients. Delay in surgical tactics significantly worsens the prognosis. Conclusions. The most serious complaint that complicates full-fledged hemodialysis is pain due to ischemia of all three nerves of the forearm, which appears or worsens during the replacement therapy procedure. Weakening of the pulse distal to the AVF is characteristic of most patients, both with proximal and distal AVF.