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Analysis of Options for Mitigating Hemodialysis Access–Related Ischemic Steal Phenomena

  • Papers Presented to the Southern California Vascular Surgical Society
  • Published:
Annals of Vascular Surgery

Abstract

Steal phenomena associated with brachial bridge grafts for hemodialysis access may compromise blood flow to the forearm. This work is designed to investigate and compare, by means of a simple mathematical model, the potential of six surgical procedures to alleviate steal. A flow model based on an electrical analogue was developed. An untapered 6-mm prosthetic brachial-axillary access (PBAA) was selected as the prototype configuration, and the theoretical effect of six access modifications on forearm flow was analyzed. Major simplifications include the use of Poiseuille’s law for estimating arterial resistance and ignoring the contribution of collateral circulation. Intra-operative flow measurements using a Transonic flowmeter were obtained in two individuals undergoing treatment for a steal syndrome. The flow model predicts that the greatest increase in distal flow is achieved by the distal revascularization–interval ligation (DRIL) procedure, followed by a 6-mm axillobrachial artery bypass graft without interval ligation, the conversion of the PBAA to an axillary-axillary loop access, and the conversion to an axillary-brachial access. Intra-operative measurements in two patients agreed closely with theoretical calculations. A simple flow model provides a tractable framework for comparing procedures designed to avoid or treat steal phenomena. Distal revascularization without interval ligation and the conversion of a PBAA to an axillary-axillary loop access or an axillary brachial access can be effective alternatives to the DRIL procedure in selected clinical settings.

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Author information

Authors and Affiliations

  1. Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Wayne S. Gradman MD

  2. Department of Fluid Mechanics, University California San Diego, San Diego, CA, USA

    Costantine Pozrikidis PhD

Authors
  1. Wayne S. Gradman MD
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  2. Costantine Pozrikidis PhD
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Corresponding author

Correspondence to Wayne S. Gradman MD.

Appendix

Appendix

The following is a more detailed analysis of the method of calculating Z, comparing an axillobrachial bypass to the prototype (Fig. 1 and Fig. 2). For both configurations, assuming an aortic blood pressure of 100 mmHg, the total flow in the arm is

In both configurations, Q T divides into parallel branches, Q F and Q C , at the elbow. It can be shown that

Defining Z as the ratio of Q C (distal brachial flow) after intervention to Q2 in the prototype,

The value for aortic pressure (100 mmHg) cancels, as it does in the calculation of Z for all six procedures. Defined resistances of 1.0 for R F and 50.0 for R C are substituted to facilitate calculation. Further reduction leaves an equation for Z that includes only the variables R A and R B ,

Appropriate substitutions are made to obtain a function relating Z to D A and D B . The final equation is plotted using a Matlab graph.

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Gradman, W.S., Pozrikidis, C. Analysis of Options for Mitigating Hemodialysis Access–Related Ischemic Steal Phenomena. Ann Vasc Surg 18, 59–65 (2004). https://doi.org/10.1007/s10016-003-0103-1

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  • DOI: https://doi.org/10.1007/s10016-003-0103-1

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