Utilisation of Bicipital Aponeurosis for Banding to Treat the Dialysis Access Steal Syndrome (DASS) in High Flow Brachial-Cephalic Arterio-Venous Fistula: A Case Report

We present a case of 36 years old male with end stage renal failure, hemodialysed for 3 years, who developed symptomatic Dialysis Access Steal Syndrome (DASS) in his right hand due to high flow brachial–cephalic arterio-venous fistula. Surgical treatment of steal syndrome was performed by aneurysmorrhaphy of draining cephalic vein, reinforced by the use of the part of bicipital aponeurosis as a native material for external banding. Intra-operative ultrasound showed immediate decrease of flow through the fistula, which dropped down from 2,6 L/min. to 900 mL/min. In postoperative period we observed complete recovery from upper limb ischemia symptoms. Patient received renal transplant 11 months later. During the follow up period, we did not observe any symptoms of DASS recurrence or infection and the fistula provided adequate hemodialysis. In selected patients, utilisation of bicipital aponeurosis as a native material for banding to treat DASS in high flow upper arm arterio-venous fistulas may be an alternative for PTFE (polytetrafluoroethylene) external cuff or PTFE graft axial interposition procedures. Przywara S*, Ilzecki M, Terlecki P and Zubilewicz T Department of Vascular Surgery and Angiology, Medical University of Lublin, Poland Przywara S, et al., Clinics in Surgery Vascular Surgery Remedy Publications LLC., | http://clinicsinsurgery.com/ 2016 | Volume 1 | Article 1152 2 as a native material for banding to reduce the steal syndrome and high flow. The area of arterio-venous anastomosis was explored with s-shape incision of the skin, what enabled exposure of anastomosis and aneurysmal segment of cephalic vein. The aneurysm of draining cephalic vein underwent narrowing aneurysmorrhaphy with an excision of superfluous wall of the aneurysm (Figure 1). Reduction of the diameter of the vein during aneurysmorrhaphy was continuously monitored by intra-operative ultrasound to achieve the reduction of the flow to the level of 800-900 ml/min. as recommended by DOQI guidelines [5]. Narrowing of the arterio-venous anastomosis was not necessary, because the preoperative ultrasound showed the maximal diameter of anastomosis of 4 mm. Part of aponeurosis was excised as shown on the Figure 2. Then, the excised part of aponeurosis was duplicated and re-sutured to form a native material for external cuff (Figure 2). Finally, previously prepared band, made of native bicipital aponeurosis, was wrapped around the narrowed vein and sutured (Figure 3). A few additional stiches secured the position of this external cuff in place, thus preventing any movements of the band, incidentally caused by high pressure, pulsative flow through the vein.