Treatment of vascular access-related steal syndrome by means of juxta-anastomotic vein interposition of a prosthetic graft segment

array:21 ["pii" => "X2013251414053924" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2014.Jan.12262" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2014;34:235-42" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 10178 "formatos" => array:3 [ "EPUB" => 341 "HTML" => 8387 "PDF" => 1450 ] ] "Traduccion" => array:1 [ "es" => array:17 [ "pii" => "X0211699514053927" "issn" => "02116995" "doi" => "10.3265/Nefrologia.pre2014.Jan.12262" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia. 2014;34:235-42" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 21949 "formatos" => array:3 [ "EPUB" => 434 "HTML" => 20264 "PDF" => 1251 ] ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Tratamiento del síndrome de robo del acceso vascular mediante interposición yuxtaanastomótica de un segmento protésico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "235" "paginaFinal" => "242" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Treatment of vascular access-related steal syndrome by means of juxta-anastomotic vein interposition of a prosthetic graft segment" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12262_19904_52563_es_12262_f1.jpg" "Alto" => 249 "Ancho" => 700 "Tamanyo" => 91069 ] ] "descripcion" => array:1 [ "es" => "Imágenes intraoperatorias de la técnica de interposición protésica, una de ellas (B) con ligadura adicional de colaterales venosas no útiles (vena basílica proximal)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Gaspar Mestres, Néstor Fontseré, Ramón Bofill, César García-Madrid, Nicolás García-Ortega, Fredy Rojas, Marta Barrufet, Vicente Riambau" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Gaspar" "apellidos" => "Mestres" ] 1 => array:2 [ "nombre" => "Néstor" "apellidos" => "Fontseré" ] 2 => array:2 [ "nombre" => "Ramón" "apellidos" => "Bofill" ] 3 => array:2 [ "nombre" => "César" "apellidos" => "García-Madrid" ] 4 => array:2 [ "nombre" => "Nicolás" "apellidos" => "García-Ortega" ] 5 => array:2 [ "nombre" => "Fredy" "apellidos" => "Rojas" ] 6 => array:2 [ "nombre" => "Marta" "apellidos" => "Barrufet" ] 7 => array:2 [ "nombre" => "Vicente" "apellidos" => "Riambau" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "X2013251414053924" "doi" => "10.3265/Nefrologia.pre2014.Jan.12262" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053924?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699514053927?idApp=UINPBA000064" "url" => "/02116995/0000003400000002/v0_201502091349/X0211699514053927/v0_201502091350/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "X2013251414053916" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2014.Feb.12455" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2014;34:243-62" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 17668 "formatos" => array:3 [ "EPUB" => 435 "HTML" => 15667 "PDF" => 1566 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Consensus document for the detection and management of chronic kidney disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "243" "paginaFinal" => "262" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso para la detección y manejo de la enfermedad renal crónica" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12455_16025_56728_en_t1.jpg" "Alto" => 1912 "Ancho" => 1053 "Tamanyo" => 415791 ] ] "descripcion" => array:1 [ "en" => "Chronic kidney disease risk factors" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => " Grupo de Redactores, Grupo de redactores, Alberto Martínez-Castelao, José L. Górriz-Teruel, Jordi Bover-Sanjuán, Julián Segura-de la Morena, Jesús Cebollada, Javier Escalada, Enric Esmatjes, Lorenzo Fácila, Javier Gamarra, Silvia Gràcia, Julio Hernánd-Moreno, José L. Llisterri-Caro, Pilar Mazón, Rosario Montañés, Francisco Morales-Oliva, Manuel Muñoz-Torres, Pedro de Pablos-Velasco, Ana de Santiago, Marta Sánchez-Celaya, Carmen Suárez, Salvador Tranche" "autores" => array:23 [ 0 => array:1 [ "apellidos" => "Grupo de Redactores" ] 1 => array:1 [ "apellidos" => "Grupo de redactores" ] 2 => array:2 [ "nombre" => "Alberto" "apellidos" => "Martínez-Castelao" ] 3 => array:2 [ "nombre" => "José L." "apellidos" => "Górriz-Teruel" ] 4 => array:2 [ "nombre" => "Jordi" "apellidos" => "Bover-Sanjuán" ] 5 => array:2 [ "nombre" => "Julián" "apellidos" => "Segura-de la Morena" ] 6 => array:2 [ "nombre" => "Jesús" "apellidos" => "Cebollada" ] 7 => array:2 [ "nombre" => "Javier" "apellidos" => "Escalada" ] 8 => array:2 [ "nombre" => "Enric" "apellidos" => "Esmatjes" ] 9 => array:2 [ "nombre" => "Lorenzo" "apellidos" => "Fácila" ] 10 => array:2 [ "nombre" => "Javier" "apellidos" => "Gamarra" ] 11 => array:2 [ "nombre" => "Silvia" "apellidos" => "Gràcia" ] 12 => array:2 [ "nombre" => "Julio" "apellidos" => "Hernánd-Moreno" ] 13 => array:2 [ "nombre" => "José L." "apellidos" => "Llisterri-Caro" ] 14 => array:2 [ "nombre" => "Pilar" "apellidos" => "Mazón" ] 15 => array:2 [ "nombre" => "Rosario" "apellidos" => "Montañés" ] 16 => array:2 [ "nombre" => "Francisco" "apellidos" => "Morales-Oliva" ] 17 => array:2 [ "nombre" => "Manuel" "apellidos" => "Muñoz-Torres" ] 18 => array:2 [ "nombre" => "Pedro" "apellidos" => "de Pablos-Velasco" ] 19 => array:2 [ "nombre" => "Ana" "apellidos" => "de Santiago" ] 20 => array:2 [ "nombre" => "Marta" "apellidos" => "Sánchez-Celaya" ] 21 => array:2 [ "nombre" => "Carmen" "apellidos" => "Suárez" ] 22 => array:2 [ "nombre" => "Salvador" "apellidos" => "Tranche" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699514053919" "doi" => "10.3265/Nefrologia.pre2014.Feb.12455" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699514053919?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053916?idApp=UINPBA000064" "url" => "/20132514/0000003400000002/v0_201502091616/X2013251414053916/v0_201502091616/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "X2013251414053736" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2013.Dec.12303" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2014;34:230-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6852 "formatos" => array:3 [ "EPUB" => 344 "HTML" => 5702 "PDF" => 806 ] ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "Acute rejection of non-functional renal grafts in dialysis patients after starting treatment with interferon and ribavirin" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "230" "paginaFinal" => "234" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rechazo agudo del injerto renal no funcionante en pacientes en diálisis después de iniciar tratamiento con interferón y ribavirina" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12303_16025_56345_en_t1_12.12303i4_copy1.jpg" "Alto" => 742 "Ancho" => 2146 "Tamanyo" => 241229 ] ] "descripcion" => array:1 [ "en" => "Previous experience." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Teresa Cavero-Escribano, Enrique Morales-Ruiz, M. Teresa Manzano-Peña, Raquel Muñoz-Gómez, Eduardo Hernández-Martínez, Eduardo Gutiérrez-Martínez, Manuel Praga-Terente" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Teresa" "apellidos" => "Cavero-Escribano" ] 1 => array:2 [ "nombre" => "Enrique" "apellidos" => "Morales-Ruiz" ] 2 => array:2 [ "nombre" => "M. Teresa" "apellidos" => "Manzano-Peña" ] 3 => array:2 [ "nombre" => "Raquel" "apellidos" => "Muñoz-Gómez" ] 4 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Hernández-Martínez" ] 5 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Gutiérrez-Martínez" ] 6 => array:2 [ "nombre" => "Manuel" "apellidos" => "Praga-Terente" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699514053739" "doi" => "10.3265/Nefrologia.pre2013.Dec.12303" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699514053739?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053736?idApp=UINPBA000064" "url" => "/20132514/0000003400000002/v0_201502091616/X2013251414053736/v0_201502091616/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Treatment of vascular access-related steal syndrome by means of juxta-anastomotic vein interposition of a prosthetic graft segment" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "235" "paginaFinal" => "242" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Gaspar Mestres, Néstor Fontseré, Ramón Bofill, César García-Madrid, Nicolás García-Ortega, Fredy Rojas, Marta Barrufet, Vicente Riambau" "autores" => array:8 [ 0 => array:3 [ "nombre" => "Gaspar" "apellidos" => "Mestres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Néstor" "apellidos" => "Fontseré" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Ramón" "apellidos" => "Bofill" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => "César" "apellidos" => "García-Madrid" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 4 => array:3 [ "nombre" => "Nicolás" "apellidos" => "García-Ortega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 5 => array:3 [ "nombre" => "Fredy" "apellidos" => "Rojas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 6 => array:3 [ "nombre" => "Marta" "apellidos" => "Barrufet" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 7 => array:3 [ "nombre" => "Vicente" "apellidos" => "Riambau" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad Funcional de Acceso Vascular. Sección de Cirugía Vascular. Servicio de Cirugía Cardiovascular. Instituto Clínico del Tórax, Hospital Clínic. UB., Barcelona, " "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Unidad Funcional de Acceso Vascular. Servicio de Nefrología, Hospital Clínic. UB., Barcelona, " "etiqueta" => "b" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Servicio de Angiología, Cirugía Vascular y Endovascular, Hospital Vall d'Hebron. UAB., Barcelona, " "etiqueta" => "c" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Unidad Funcional de Acceso Vascular. Servicio de Angiorradiología, Hospital Clínic. UB., Barcelona, " "etiqueta" => "d" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento del síndrome de robo del acceso vascular mediante interposición yuxtaanastomótica de un segmento protésico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12262_16025_56446_en_t1_13.12262_032.jpg" "Alto" => 519 "Ancho" => 2150 "Tamanyo" => 190649 ] ] "descripcion" => array:1 [ "en" => "Description of the types of arteriovenous accesses addressed in the series." ] ] ] "textoCompleto" => "INTRODUCTION Arteriovenous fistula (AVF) is the method of choice for vascular access during haemodialysis sessions in patients with end-stage renal failure, because, compared with prosthetic arteriovenous or central venous catheters, it is associated with lower complication rates.1,2 However, there is a specific complication of AVF or prosthetic grafts that can be severe and even jeopardize the viability of the affected limb: steal syndrome.Steal syndrome is caused by a decrease in distal blood perfusion due to a proximal preferred blood flow outlet through the vascular access vein, with less resistance than the distal arterial bed.3 Despite being a physiological phenomenon observed in up to 73% of AVFs and 91% of prostheses (steal syndrome grade I),4 it can cause symptoms in up to 8% of accesses5: pain during dialysis (grade II), pain at rest (grade III) or ulceration and necrosis (grade IV).6 When these symptoms occur, especially grades III and IV, endovascular or surgical procedures are required to restore distal blood flow and prevent irreversible injury or amputation, maintaining patency and the use of the vascular access, if possible.The treatments proposed for steal syndrome include a variety of techniques: ligature (usually effective, but resulting in access loss), repair of associated arterial lesions proximal or distal7, ligature of the distal radial artery (DRAL)8 or proximal vascular access (PRAL)9 in steal cases at the palmar arch in distal cephalic fistulae, proximalisation or distalisation of the anastomosis (PAVA and RUDI)10,11, flow reduction techniques (such as banding, with unpredictable results if performed without intraoperative monitoring, or variants of it, such as MILLER12, external banding with prosthetic bands13,14 or simple ligature of non-useful collateral veins15,16), or DRIL3,17 (distal revascularization by interposition of an arterial bypass and ligature of the native artery). The results offered by these techniques are variable, maintaining access and resolving ischemic symptoms in up to 77% of cases treated with DRIL. However, many of them are complex and induce morbidity.3The aim of this study is to present the initial results of a simple and effective technique to treat steal syndrome: reduction of vascular access flow (and increased distal arterial perfusion) by interposing a prosthetic graft segment in the juxta-anastomotic vein. MATERIAL AND METHOD Our vascular access unit (UFAV, Hospital Clínic, Universidad de Barcelona; Barcelona, Spain) offers a multidisciplinary approach to patients requiring vascular access for haemodialysis, and is a referral centre for patients in our health district and other centres with regards to creation and repair of vascular access. All patients evaluated and treated by our unit are systematically entered prospectively into a multidisciplinary database, which collects basic data, comorbidities, previous vascular accesses, a detailed history and physical and routine ultrasound examinations. All surgical procedures are also noted, once again with a physical examination and intraoperative and immediate postoperative results as also postoperative follow-up.For this study, we included all patients that came to our unit between 2009 and 2012 for symptomatic steal syndrome secondary to a native arteriovenous vascular access performed in our unit or in other centres. Symptomatic steal syndrome was defined as pain at dialysis, constant pain or ulceration (grades II, III and IV) in the hand or forearm of the vascular access, usually associated with other signs of hand ischemia (pallor, coldness) and after ruling out other differential diagnoses by physical examination and selective complementary examinations (carpal tunnel syndrome, joint pain, high venous pressure, etc.).During the study period, our unit evaluated 51 patients with persistent symptomatic steal syndrome. After an individual assessment and discussion of each case, a physical examination, routine ultrasound, and selective angio-radiological study, we excluded from the series renal transplant patients with normally functioning kidneys (they underwent access ligature), subsidiary accesses to be repaired with other techniques (proximal or distal arterial stenosis treated with endovascular procedures, distal accesses treated by DRAL, simple ligature of useless venous collaterals in proximal accesses), useless accesses, presence of severe distal artery diseases, those cases associated with very extensive ulcerated lesions, poor health conditions or patient preference.In brachio-basilic side to side fistulae with several output drainage veins (basilic, elbow perforating and/or cephalic vein), we chosed to perform a simple ligature of useless venous collaterals when the diameter of one of these was greater than 4 mm, and to add a prosthetic interposition to the useful vein (in addition to useless collaterals ligature) when said collaterals were all smaller. We dismissed making this decision based on flow, given the difficulty and unreliability of calculating this with ultrasounds, especially for the perforating elbow vein.Finally, 14 cases were included, which were treated with the prosthetic interposition technique. A segment of straight tubular 6 mm prosthesis made of polytetrafluoroethylene (PTFE) graft, 2cm long, was interposed in the juxta-anastomotic venous segment by end to end anastomosis of both venous stumps (Figure 1). Useless venous collaterals (less than 4mm in diameter) were ligated in side to side brachio-basilic AVF, and when the preoperative study (ultrasound and/or angiography) showed perianastomotic artery stenosis, this was repaired by patch angioplasty, in addition to interposition of the juxta-anastomotic prosthetic segment.In addition to patients’ basic and clinical preoperative, the following were collected in a prospective database:Preoperative Examination: physical exam (grade of steal syndrome), ultrasound examination (prior vascular access type, location, venous drainage, arterial and venous diameters, systolic, diastolic and mean speeds in the proximal artery [2cm proximal to the anastomosis] and distal radial artery in the wrist).Intraoperative Examination: procedure performed, immediate physical examination (pulse, palpable thrill, murmur at access, distal arterial pulse) and ultrasound (same preoperative measurements).Follow-up: postoperative follow-up of clinical symptoms and adequacy of access for haemodialysis sessions, patency and need for secondary procedures.All surgeries and examinations were performed by the same surgeon, using the same ultrasound device: SonoSite MicroMaxx Ultrasound System (Sonosite Inc, WA, USA) and a HFL38/13-6 MHz 38 mm linear array transducer, adjusting and steering the pulsed wave doppler angle to 60º to vessel direction and gate size to vessel diameter. Intra-operative measurements were recorded in the operating room, during surgery and after anastomosis creation; aseptic conditions were taken into account. These measurements were not considered in surgery decisions. Velocities (PSV, EDV, MV) and RI were automatically calculated, and vessel diameter (adventitia-adventitia) was manually measured. Flows (mL/min) were calculated using manufacturer proposed parameters: cross sectional area (0.785xD2, in cm2) x time averaged mean velocity (MV, in cm/s) x conversion factor (0.06). All pre- and intra-operative measurements were always taken in the same place.Vascular access flow was estimated according to the flow of the proximal artery as the most reliable method,18,19 dismissing vein flow rates (less reliable18,19 and as several draining veins exist which in many cases affect this interpretation). Total distal arterial perfusion flow was not calculated, because there are several drainage distal arteries (radial, ulnar, interosseous) that should be added and due to the technical and computer complexity that this entails, in spite of, changes in distal radial artery flow were calculated and considered an estimate of overall changes in distal perfusion. Statistics Frequency and descriptive statistics were obtained, and comparisons were performed using SPSS software, version 19.0, describing medians and ranges or interquartile ranges (25-75 percentiles) and percentages. Changes in flows were defined as percentages of change ([preoperative-postoperative]/preoperative), and were described as medians and interquartile ranges. Statistical differences between groups were evaluated using the Wilcoxon signed rank test for comparisons of pre-postoperative flows. Measures of time to event were analyzed using Kaplan- Meier survival analysis, with estimated percentages at 12 and 24 months. A P value <.05 was considered to be statistically significant. RESULTS The 14 patients included in this study (57% male, median age 72 years) had a high percentage of comorbidities (86% hypertension, 78% smoking history, 71% dyslipidaemia, 57% ischaemic heart disease, 43% diabetes mellitus, 29% severe symptomatic peripheral artery disease, 21% chronic obstructive pulmonary disease). All were on renal replacement therapy by hemodialysis for a median of 1.1 years (range 0.2 to 5.1), although the actual arteriovenous access was made 1.5 years earlier (range 0.1 to 12.7), it was a secondary access in 50% of cases. All had symptomatic steal syndrome (grade II: 2, grade III: 8, grade IV: 4).Original AVF accesses are described in Table 1. All of them were proximal fistulae with a cephalic or basilic drainage vein, or both. As has already been described in side to side brachio-basilic fistulae the elbow perforating vein or other useless veins (proximal basilic or cephalic) were occluded or were under 4mm in diameter. 71% of accesses were in the left arm.All cases were treated using the juxta-anastomotic prosthetic interposition technique (described above). Arterial anastomotic stenoses were diagnosed in 2 cases and repaired by an additional arterial patch angioplasty. In the 8 cases of side to side, brachio-basilic arteriovenous fistulae, we also carried out a ligature of small useless collateral veins (perforating veins or proximal basilic of less than 4mm in diameter), and in 5 we performed a superficial transposition of the proximal basilic vein. All cases were performed under local or regional anaesthesia and as hospital outpatients without hospital admittance.The technical success of the procedure was 100%. Pre- and postoperative ultrasonography showed immediate access flow reduction of 39% (proximal arterial flow) and an increase in the flow of the distal radial artery of 477% (Table 2).Ischaemic symptoms completely disappeared and ischaemic lesions healed following the prosthetic interposition technique in 12 cases (86%, Figure 2). However, the other two cases showed partial improvement with persistent ischemic pain, eventually requiring access ligature within three months of follow up. Technical failure was attributed to a proximal arterial stenosis not initially diagnosed and to an artery of small calibre and low flow. Both cases, after initial repair, had the lowest increase in distal blood flow and access flow decrease in all the series. The postoperative complication occurred due to rupture of an excessively dilated basilic vein that had undergone superficial transposition, three days after the initial procedure, which required a permanent access ligature. There were no minor or major amputations in any case after surgery or during follow-up.Mean follow-up was 12.04 months (range 0.2 to 33.5). There were no losses to follow-up, there were no new ischaemic symptoms, or access thrombosis and only one reintervention (balloon angioplasty) performed because of stenosis of the interposed prosthesis during follow up. Therefore, primary, assisted primary and secondary patency free from ischaemic symptoms were 78%, 78% and 78% at 12 months and 62%, 78% and 78% at 24 months, respectively (Figure 3). DISCUSSION Steal syndrome is caused by a decrease in distal blood perfusion due to a proximal preferred blood flow outlet through the vascular access vein, with less resistance than the distal arterial bed.3 Some cases of steal syndrome can be repaired with specific treatments (proximal or distal arterial stenosis can usually be treated with endovascular techniques, steal syndromes in radio-cephalic fistulae due to palmar arch steal can be repaired by DRAL8 or other syndromes of excess venous output due to large collaterals can be treated with simple non-useful vein ligatures15,16).However, in many cases of proximal accesses without arterial lesions or large useless collateral veins, steal syndrome is directly due to excess flow from the artery to the venous outflow to the detriment of the distal arterial system. In these cases, the treatment proposed by our group (the juxta-anastomotic vein interposition of a prosthetic 6mm graft segment, with selective repair of arterial stenoses with patch angioplasty and ligature of useless collateral veins) partially reverses this condition reducing the overall fistula flow and increasing distal blood perfusion. These flow changes have been seen by echographic measurement. Overall reduction of access flow by 39% and increase in distal radial artery flow in 477% (it therefore follows that there is a reduction in access flow at the expense of a reduction in venous outflow, thereby increasing distal arterial blood perfusion). Furthermore, results at two years follow-up are promising (assisted primary and secondary patency 78%).Prosthetic interposition technique is a flow reduction technique (a variant of classical banding, but controlling diameter and length), thus increasing distal arterial perfusion pressure. Other flow reduction techniques have been effective, but have unpredictable results. The most widely used world-wide is banding, which is a partial ligature of the juxta-anastomotic vein. Although effective in some cases, it has been related to non-consistent results and high failure rates due to excessively tight or loose ligatures. To ensure ligature diameter, techniques such as MILLER banding have been designed (ensuring ligature diameter with an endoluminal ball),12 banding assisted by a dilator20 or monitored intraoperatively with flow and digital pressure measurements,21 thus obtaining better results. The use of prosthetic segments as external banding, to reduce vein diameter13,14, has also shown better results than usual banding, however, depending on vein diameter, there are concerns with regards to the risk of stenosis and thrombosis due to excess intra-banding fold tissue.Other techniques such as PAVA or RUDI10,11 or interposition of long loop prosthetic segments22 are more complex procedures, which use longer prosthetic segments and have an increased risk of thrombosis, but have the same objective as the procedure presented: to reduce access flow by reducing vessel diameter to that of the interposed prosthetic segment, and therefore the same result is obtained.The most commonly used technique to treat steal syndrome is probably DRIL3,17: using a humeral-humeral arterial bypass proximally to distally of the arteriovenous anastomosis (usually with a segment of saphenous vein) plus ligature of the native artery (between the original fistula and distal bypass anastomosis). Thus, native artery from the origin of the bypass to the arteriovenous anastomosis (of smaller diameter than the bypass, and especially and definitely smaller diameter than the outflow vein) acts like a stenosis with regards to venous outflow. From this perspective, and in spite of other less understandable haemodynamic explanations, DRIL achieves the same objective as prosthetic interposition: it causes a decrease in the size of the vessel connecting the arterial system to the venous outflow (in DRIL: the native artery, and in the interposition technique: a prosthetic segment), to produce a decreased flow from the proximal artery to the vein and increase distal arterial blood flow. However, DRIL uses a more complex technique with greater morbidity than the interposition technique for the same purpose, with the risk that bypass complications may cause arm ischaemia.3 In the interposition technique, procedure occlusion only affects arteriovenous access and not arm viability. Furthermore, DRIL has achieved a percentage of early successes and patency close to 77%, similar to the prosthetic interposition technique.The three initial complications that occurred in our series could probably have been avoided. To superficially transpose an excessively dilated vein increases the risk of bleeding and should not have been performed, but instead replaced with a prosthetic access. A diagnostic error was responsible for not diagnosing proximal arterial stenosis, which might have been previously treated and so made it possible to avoid prosthetic interposition. And in arteries of small calibre repairs should be performed with smaller diameter prostheses (4mm).Fistula ultrasound and compression studies showed two cases of arterial stenosis in the distal segment of the original anastomosis. These cases required, in addition to prosthetic interposition, repair by means of an arterial patch angioplasty. Possibly these would have been good candidates for repair using DRIL, saving the arterial stenosis with a bypass, but with this technique both defects were treated: the arterial stenosis and excess vein output flow. Other procedures, such as ligature of useless collateral veins or superficial transposition of a proximal basilic vein are important to complete flow reduction and increase the usefulness of the final access.As previously described, in side to side brachio-basilic fistulae with useless collateral vein drainage (proximal basilic or elbow perforating veins), a simple ligature of these may be sufficient to resolve steal syndrome.15 But given our previous bad experience with this technique and the difficulty and unreliability when calculating collateral flow with echo-Doppler, especially for perforating elbow vein (hard to measure or selectively compress), we chose to ligate said collateral when they were patent and greater than 4mm diameter. Only when these were smaller, did we add the prosthetic interposition technique to ligature, since simple ligature could be responsible for procedure failure due to insufficient reduction of access flow. Maybe in the future, following the results presented, ultrasound monitoring of intraoperative pre and post ligature flows of simple collaterals (rather than their diameter or systematic simple ligature and clinical follow-up) could help define what side to side accesses require performance of the prosthetic interposition technique.For this study a portable conventional duplex device for morphologic and flow diameters was used. Despite being very useful, easy to use even under intraoperative conditions and available in most services, estimated flows may be higher and there is a low correlation with other more reliable techniques (ultrasound dilution rate or quantitative speed colour indices); the reason is probably the high susceptibility of conventional Doppler to turbulent flows.23 Precisely for this reason, many groups recommend measuring flow in the proximal artery as an estimate of the extent of access flow, avoiding vein measurements: this bears a better relationship to access flow, has a more laminar flow, with a regular wall, circular area and is more difficult to compress with the probe.18,19 This was the reason for estimating arteriovenous access flow by proximal arterial flow.There are several limitations to the validity of our study: it is a short series, without a control group, in which comparisons are difficult, and ultrasound measurements may have system errors. Moreover, as already discussed, in some cases in the series simple ligature of collateral veins could have been an alternative treatment to interposition plus collateral ligature.In conclusion, the interposition of a prosthetic graft segment in the juxta-anastomotic vein, with selective repair of arterial stenosis with patch angioplasty and ligature of useless venous collaterals, can effectively treat symptomatic steal syndrome caused by an arteriovenous vascular access, increasing distal arterial perfusion and reducing the access flow. Despite some avoidable mistakes in our series, this technique is promising at two years follow-up. Its possible indications are symptomatic steal syndromes (grade II to IV) in proximal arteriovenous accesses without associated proximal arterial lesions or large patent useless venous collaterals, and demonstrated hyperflow. Conflicts of interest The authors declare that they have no conflicts of interest related to the contents of this article.<a href="grande/12262_16025_56446_en_t1_13.12262_032.jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56446_en_t1_13.12262_032.jpg" alt="Description of the types of arteriovenous accesses addressed in the series."></img></a>Table 1. Description of the types of arteriovenous accesses addressed in the series.<a href="grande/12262_16025_56447_en_t2_13.12262_03.jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56447_en_t2_13.12262_03.jpg" alt="Comparison of pre and post operative flows in the proximal humeral artery and distal radial artery (medians and interquartile ranges, and% of change)"></img></a>Table 2. Comparison of pre and post operative flows in the proximal humeral artery and distal radial artery (medians and interquartile ranges, and% of change)<a href="grande/12262_16025_56448_en_f113.12262_03.jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56448_en_f113.12262_03.jpg" alt="Intraoperative images of the interposition of a prosthetic segment , one (B) with additional ligature of non-useful collateral veins (proximal basilic vein). "></img></a>Figure 1. Intraoperative images of the interposition of a prosthetic segment , one (B) with additional ligature of non-useful collateral veins (proximal basilic vein). <a href="grande/12262_16025_56449_en_f213.12262_03.jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56449_en_f213.12262_03.jpg" alt=" Ischaemic lesion in 5th finger of the hand, secondary to a steal syndrome due to a brachio-cephalic arteriovenous fistula (A); improvement of lesion 2 weeks after repair using the interposition graft technique (B)."></img></a>Figure 2. Ischaemic lesion in 5th finger of the hand, secondary to a steal syndrome due to a brachio-cephalic arteriovenous fistula (A); improvement of lesion 2 weeks after repair using the interposition graft technique (B).<a href="grande/12262_16025_56450_en_f3_13.12262_03.jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56450_en_f3_13.12262_03.jpg" alt="Kaplan-Meier survival function."></img></a>Figure 3. Kaplan-Meier survival function." "pdfFichero" => "P1-E567-S4556-A12262-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438849" "palabras" => array:1 [ 0 => "Robo" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438851" "palabras" => array:1 [ 0 => "Complicaciones" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438853" "palabras" => array:1 [ 0 => "Hemodiálisis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438855" "palabras" => array:1 [ 0 => "Fístula arterio-venosa" ] ] ] "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438850" "palabras" => array:1 [ 0 => "Vascular access-related steal syndrome" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438852" "palabras" => array:1 [ 0 => "Complications" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438854" "palabras" => array:1 [ 0 => "Haemodialysis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438856" "palabras" => array:1 [ 0 => "Arteriovenous fistula" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "Objetivos: El síndrome de robo es una complicación grave del acceso vascular. Nuestro objetivo es presentar los resultados iniciales de un tratamiento simple y eficaz: la interposición de un segmento protésico en la vena yuxtaanastomótica. Métodos: Entre 2009 y 2012, 14 pacientes (57 % varones, edad media 71 años) con síndrome de robo severo por un acceso vascular nativo (grados II-IV), y tras un estudio clínico y ecográfico sistemático, y angiográfico selectivo, fueron tratados mediante la interposición de un segmento de prótesis tubular, politetrafluoroetileno (PTFE) de 6 mm de diámetro en la vena yuxtaanastomótica, más reparación selectiva de estenosis arterial mediante parche (2 casos) o ligadura de colaterales venosas no útiles (8 casos). Se utilizó anestesia local o regional y un régimen ambulatorio en todos los casos. Resultados: El éxito técnico fue del 100 %. El estudio ecográfico pre y posoperatorio mostró una reducción del flujo posoperatorio del acceso del 39 % y un aumento del flujo arterial radial del 477 %. Los síntomas isquémicos se resolvieron en 12 pacientes (86 %); los otros dos requirieron procedimientos adicionales por síntomas isquémicos persistentes. Ocurrió una ruptura venosa posoperatoria, que requirió una ligadura definitiva. Ningún caso sufrió amputaciones ni hubo pérdidas ni trombosis del acceso en el seguimiento. Las permeabilidades primaria y primaria asistida libres de nuevos síntomas isquémicos fueron del 78 % y del 78 % a los 12 meses, y del 62 % y del 78 % a los 24 meses. Conclusiones: La interposición de un segmento protésico yuxtaanastomótico es una técnica sencilla, rápida y eficaz en el tratamiento del síndrome de robo vascular, con resultados prometedores a dos años de seguimiento." ] "en" => array:1 [ "resumen" => "Objective: Steal syndrome is a severe complication of vascular access. Our aim is to present the initial results of a simple and effective treatment: the interposition of a prosthetic segment in the juxta-anastomotic vein. Method: Between 2009 and 2012, 14 patients (57 % male, average age 71) with severe steal syndrome due to vascular access (stages II-IV), following a clinical and systematic echographic study and a selective angiographic study, were treated through the interposition of a 6 mm segment of PTFE in the juxta-anastomotic vein, in addition to selective patch repair of arterial stenosis (2 cases) or ligature of useless venous collaterals (8 cases). Local or regional anaesthesia was used and outpatient care was given in all cases. Results: There was 100 % technical success. The pre- and post-operative echographical study showed a reduction of post-operative access flow by 39 % and an increase of radial artery flow by 477 %. Ischaemic symptoms were resolved in 12 patients (86 %); the other two patients required additional procedures due to persistent ischaemic symptoms. There was a post-operative venous rupture, which required a definitive ligation. No patient suffered amputations, nor were there losses or access thrombosis during the follow-up. The primary and primary-assisted patencies free of new ischemic symptoms were 78 % and 78 % at 12 months, and 62 % and 78 % at 24 months. Conclusions: The interposition of a prosthetic segment in the juxta-anastomotic vein is a simple, quick and effective technique in the treatment of vascular steal syndrome, with promising results at the 2 year follow-up." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12262_16025_56446_en_t1_13.12262_032.jpg" "Alto" => 519 "Ancho" => 2150 "Tamanyo" => 190649 ] ] "descripcion" => array:1 [ "en" => "Description of the types of arteriovenous accesses addressed in the series." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12262_16025_56447_en_t2_13.12262_03.jpg" "Alto" => 273 "Ancho" => 2157 "Tamanyo" => 163532 ] ] "descripcion" => array:1 [ "en" => "Comparison of pre and post operative flows in the proximal humeral artery and distal radial artery (medians and interquartile ranges, and% of change)" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12262_16025_56448_en_f113.12262_03.jpg" "Alto" => 348 "Ancho" => 1010 "Tamanyo" => 171374 ] ] "descripcion" => array:1 [ "en" => "Intraoperative images of the interposition of a prosthetic segment , one (B) with additional ligature of non-useful collateral veins (proximal basilic vein)." ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12262_16025_56449_en_f213.12262_03.jpg" "Alto" => 616 "Ancho" => 1002 "Tamanyo" => 237260 ] ] "descripcion" => array:1 [ "en" => "Ischaemic lesion in 5th finger of the hand, secondary to a steal syndrome due to a brachio-cephalic arteriovenous fistula (A); improvement of lesion 2 weeks after repair using the interposition graft technique (B)." ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12262_16025_56450_en_f3_13.12262_03.jpg" "Alto" => 966 "Ancho" => 2113 "Tamanyo" => 273183 ] ] "descripcion" => array:1 [ "en" => "Kaplan-Meier survival function." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48 Suppl 1:S176-247. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16813989" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Tordoir J, Canaud B, Haage P, Konner K, Basci A, Fouque D, et al. EBPG on Vascular Access. Nephrol Dial Transplant 2007;22 Suppl 2:ii88-117." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Anaya-Ayala JE, Pettigrew CD, Ismail N, Diez-De Sollano AL, Syed FA, Ahmed FG, et al. Management of dialysis access-associated ¿steal¿ syndrome with DRIL procedure: challenges and clinical outcomes. J Vasc Access 2012;13(3):299-304. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22266588" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Zamani P, Kaufman J, Kinlay S. Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis. Vasc Med 2009;14(4):371-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19808723" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Rocha A, Silva F, Queirós J, Malheiro J, Cabrita A. Predictors of steal syndrome in hemodialysis patients. Hemodial Int 2012;16(4):539-44. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22510166" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mickley V. Steal syndrome--strategies to preserve vascular access and extremity. Nephrol Dial Transplant 2008;23(1):19-24. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17905806" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Malik J, Tuka V, Kasalova Z, Chytilova E, Slavikova M, Clagett P, et al. Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies. J Vasc Access 2008;9(3):155-66. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18850575" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Miller GA, Khariton K, Kardos SV, Koh E, Goel N, Khariton A. Flow interruption of the distal radial artery: treatment for finger ischemia in a matured radiocephalic AVF. J Vasc Access 2008;9(1):58-63. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18379982" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Bourquelot P, Gaudric J, Turmel-Rodrigues L, Franco G, Van Laere O, Raynaud A. Proximal radial artery ligation (PRAL) for reduction of flow in autogenous radial cephalic accesses for haemodialysis. Eur J Vasc Endovasc Surg 2010;40(1):94-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20359915" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Callaghan CJ, Mallik M, Sivaprakasam R, Iype S, Pettigrew GJ. Treatment of dialysis access-associated steal syndrome with the ¿revision using distal inflow¿ technique. J Vasc Access 2011;12(1):52-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21058261" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Thermann F, Wollert U, Ukkat J, Dralle H. Proximalization of the arterial inflow (PAI) in patients with dialysis access-induced ischemic syndrome: first report on long-term clinical results. J Vasc Access 2010;11(2):143-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20155715" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Miller GA, Goel N, Friedman A, Khariton A, Jotwani MC, Savransky Y, et al. The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome. Kidney Int 2010;77(4):359-66. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20010547" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Smith GE, Barnes R, Green L, Kuhan G, Chetter IC. A ¿christmas tree¿ band for the treatment of arteriovenous dialysis access-related steal syndrome. Ann Vasc Surg 2013;27(2):239.e9-239.e12." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Papalois VE, Haritopoulos KN, Farrington K, Hakim NS. Successful reversal of steal syndrome following creation of arteriovenous fistula by banding with a ringed Gore-Tex cuff: a new technique. Int Surg 2003;88(1):52-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12731732" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Moini M, Rasouli MR, Nouri M. Ligation of the perforating vein: a treatment for steal syndrome in side-to-side elbow arteriovenous fistula. Ann Vasc Surg 2008;22(2):307. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18346584" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Moini M, Williams GM, Pourabbasi MS, Rasouli MR, Tarighi P, Mardanloo A, et al. Side-to-side arteriovenous fistula at the elbow with perforating vein ligation. J Vasc Surg 2008;47(6):1274-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18467069" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Aimaq R, Katz SG. Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation. J Vasc Surg 2013;57:1073-8." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lomonte C, Casucci F, Antonelli M, Giammaria B, Losurdo N, Marchio G, et al. Is there a place for duplex screening of the brachial artery in the maturation of arteriovenous fistulas? Semin Dial 2005;18(3):243-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15934972" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wiese P, Nonnast-Daniel B. Colour Doppler ultrasound in dialysis access. Nephrol Dial Transplant 2004;19(8):1956-63. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15199165" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wang S, Almehmi A, Packer J. Dilator-assisted banding for managing complications associated with excessive hemodialysis access flow. Semin Dial 2013;26(1):100-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22548358" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Van Hoek F, Scheltinga M, Luirink M, Pasmans H, Beerenhout C. Banding of hemodialysis access to treat hand ischemia or cardiac overload. Semin Dial 2009;22(2):204-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19426430" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Henriksson AE, Bergqvist D. Steal syndrome after brachiocephalic fistula for vascular access: correction with a new simple surgical technique. J Vasc Access 2004;5(1):13-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16596533" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Zanen AL, Toonder IM, Korten E, Wittens CH, Diderich PN. Flow measurements in dialysis shunts: lack of agreement between conventional Doppler, CVI-Q, and ultrasound dilution. Nephrol Dial Transplant 2001;16(2):395-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11158420" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003400000002/v0_201502091616/X2013251414053924/v0_201502091616/en/main.assets" "Apartado" => array:4 [ "identificador" => "35448" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Technical Notes" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003400000002/v0_201502091616/X2013251414053924/v0_201502091616/en/P1-E567-S4556-A12262-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053924?idApp=UINPBA000064"]

Statistics

Tratamiento del síndrome de robo del acceso vascular mediante interposición yuxtaanastomótica de un segmento protésico

Gaspar Mestresa, Néstor Fontseréb, Ramón Bofillc, César García-Madrida, Nicolás García-Ortegaa, Fredy Rojasa, Marta Barrufetd, Vicente Riambaua

a Unidad Funcional de Acceso Vascular. Sección de Cirugía Vascular. Servicio de Cirugía Cardiovascular. Instituto Clínico del Tórax, Hospital Clínic. UB., Barcelona,

b Unidad Funcional de Acceso Vascular. Servicio de Nefrología, Hospital Clínic. UB., Barcelona,

c Servicio de Angiología, Cirugía Vascular y Endovascular, Hospital Vall d'Hebron. UAB., Barcelona,

d Unidad Funcional de Acceso Vascular. Servicio de Angiorradiología, Hospital Clínic. UB., Barcelona,

Read

17397

Times
was read the article

3488

Total PDF

13909

Total HTML

Share statistics

 array:21 [
  "pii" => "X2013251414053924"
  "issn" => "20132514"
  "doi" => "10.3265/Nefrologia.pre2014.Jan.12262"
  "estado" => "S300"
  "fechaPublicacion" => "2014-03-01"
  "documento" => "article"
  "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
  "subdocumento" => "fla"
  "cita" => "Nefrologia &#40;English Version&#41;. 2014;34:235-42"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 10178
    "formatos" => array:3 [
      "EPUB" => 341
      "HTML" => 8387
      "PDF" => 1450
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:17 [
      "pii" => "X0211699514053927"
      "issn" => "02116995"
      "doi" => "10.3265/Nefrologia.pre2014.Jan.12262"
      "estado" => "S300"
      "fechaPublicacion" => "2014-03-01"
      "documento" => "article"
      "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
      "subdocumento" => "fla"
      "cita" => "Nefrologia. 2014;34:235-42"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 21949
        "formatos" => array:3 [
          "EPUB" => 434
          "HTML" => 20264
          "PDF" => 1251
        ]
      ]
      "es" => array:12 [
        "idiomaDefecto" => true
        "titulo" => "Tratamiento del s&#237;ndrome de robo del acceso vascular mediante interposici&#243;n yuxtaanastom&#243;tica de un segmento prot&#233;sico"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "235"
            "paginaFinal" => "242"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Treatment of vascular access-related steal syndrome by means of juxta-anastomotic vein interposition of a prosthetic graft segment"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:8 [
            "identificador" => "fig1"
            "etiqueta" => "Fig. 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "copyright" => "Elsevier Espa&#241;a"
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "12262_19904_52563_es_12262_f1.jpg"
                "Alto" => 249
                "Ancho" => 700
                "Tamanyo" => 91069
              ]
            ]
            "descripcion" => array:1 [
              "es" => "Im&#225;genes intraoperatorias de la t&#233;cnica de interposici&#243;n prot&#233;sica&#44; una de ellas &#40;B&#41; con ligadura adicional de colaterales venosas no &#250;tiles &#40;vena bas&#237;lica proximal&#41;&#46;"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Gaspar Mestres, N&#233;stor Fontser&#233;, Ram&#243;n Bofill, C&#233;sar Garc&#237;a-Madrid, Nicol&#225;s Garc&#237;a-Ortega, Fredy Rojas, Marta Barrufet, Vicente Riambau"
            "autores" => array:8 [
              0 => array:2 [
                "nombre" => "Gaspar"
                "apellidos" => "Mestres"
              ]
              1 => array:2 [
                "nombre" => "N&#233;stor"
                "apellidos" => "Fontser&#233;"
              ]
              2 => array:2 [
                "nombre" => "Ram&#243;n"
                "apellidos" => "Bofill"
              ]
              3 => array:2 [
                "nombre" => "C&#233;sar"
                "apellidos" => "Garc&#237;a-Madrid"
              ]
              4 => array:2 [
                "nombre" => "Nicol&#225;s"
                "apellidos" => "Garc&#237;a-Ortega"
              ]
              5 => array:2 [
                "nombre" => "Fredy"
                "apellidos" => "Rojas"
              ]
              6 => array:2 [
                "nombre" => "Marta"
                "apellidos" => "Barrufet"
              ]
              7 => array:2 [
                "nombre" => "Vicente"
                "apellidos" => "Riambau"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "X2013251414053924"
          "doi" => "10.3265/Nefrologia.pre2014.Jan.12262"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053924?idApp=UINPBA000064"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699514053927?idApp=UINPBA000064"
      "url" => "/02116995/0000003400000002/v0_201502091349/X0211699514053927/v0_201502091350/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:17 [
    "pii" => "X2013251414053916"
    "issn" => "20132514"
    "doi" => "10.3265/Nefrologia.pre2014.Feb.12455"
    "estado" => "S300"
    "fechaPublicacion" => "2014-03-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia &#40;English Version&#41;. 2014;34:243-62"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 17668
      "formatos" => array:3 [
        "EPUB" => 435
        "HTML" => 15667
        "PDF" => 1566
      ]
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "titulo" => "Consensus document for the detection and management of chronic kidney disease"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "243"
          "paginaFinal" => "262"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Documento de consenso para la detecci&#243;n y manejo de la enfermedad renal cr&#243;nica"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig1"
          "etiqueta" => "Tab.  1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "copyright" => "Elsevier Espa&#241;a"
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "12455_16025_56728_en_t1.jpg"
              "Alto" => 1912
              "Ancho" => 1053
              "Tamanyo" => 415791
            ]
          ]
          "descripcion" => array:1 [
            "en" => "Chronic kidney disease risk factors"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => " Grupo de Redactores,  Grupo de redactores, Alberto Mart&#237;nez-Castelao, Jos&#233; L&#46; G&#243;rriz-Teruel, Jordi Bover-Sanju&#225;n, Juli&#225;n Segura-de la Morena, Jes&#250;s Cebollada, Javier Escalada, Enric Esmatjes, Lorenzo F&#225;cila, Javier Gamarra, Silvia Gr&#224;cia, Julio Hern&#225;nd-Moreno, Jos&#233; L&#46; Llisterri-Caro, Pilar Maz&#243;n, Rosario Monta&#241;&#233;s, Francisco Morales-Oliva, Manuel Mu&#241;oz-Torres, Pedro de Pablos-Velasco, Ana de Santiago, Marta S&#225;nchez-Celaya, Carmen Su&#225;rez, Salvador Tranche"
          "autores" => array:23 [
            0 => array:1 [
              "apellidos" => "Grupo de Redactores"
            ]
            1 => array:1 [
              "apellidos" => "Grupo de redactores"
            ]
            2 => array:2 [
              "nombre" => "Alberto"
              "apellidos" => "Mart&#237;nez-Castelao"
            ]
            3 => array:2 [
              "nombre" => "Jos&#233; L&#46;"
              "apellidos" => "G&#243;rriz-Teruel"
            ]
            4 => array:2 [
              "nombre" => "Jordi"
              "apellidos" => "Bover-Sanju&#225;n"
            ]
            5 => array:2 [
              "nombre" => "Juli&#225;n"
              "apellidos" => "Segura-de la Morena"
            ]
            6 => array:2 [
              "nombre" => "Jes&#250;s"
              "apellidos" => "Cebollada"
            ]
            7 => array:2 [
              "nombre" => "Javier"
              "apellidos" => "Escalada"
            ]
            8 => array:2 [
              "nombre" => "Enric"
              "apellidos" => "Esmatjes"
            ]
            9 => array:2 [
              "nombre" => "Lorenzo"
              "apellidos" => "F&#225;cila"
            ]
            10 => array:2 [
              "nombre" => "Javier"
              "apellidos" => "Gamarra"
            ]
            11 => array:2 [
              "nombre" => "Silvia"
              "apellidos" => "Gr&#224;cia"
            ]
            12 => array:2 [
              "nombre" => "Julio"
              "apellidos" => "Hern&#225;nd-Moreno"
            ]
            13 => array:2 [
              "nombre" => "Jos&#233; L&#46;"
              "apellidos" => "Llisterri-Caro"
            ]
            14 => array:2 [
              "nombre" => "Pilar"
              "apellidos" => "Maz&#243;n"
            ]
            15 => array:2 [
              "nombre" => "Rosario"
              "apellidos" => "Monta&#241;&#233;s"
            ]
            16 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Morales-Oliva"
            ]
            17 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "Mu&#241;oz-Torres"
            ]
            18 => array:2 [
              "nombre" => "Pedro"
              "apellidos" => "de Pablos-Velasco"
            ]
            19 => array:2 [
              "nombre" => "Ana"
              "apellidos" => "de Santiago"
            ]
            20 => array:2 [
              "nombre" => "Marta"
              "apellidos" => "S&#225;nchez-Celaya"
            ]
            21 => array:2 [
              "nombre" => "Carmen"
              "apellidos" => "Su&#225;rez"
            ]
            22 => array:2 [
              "nombre" => "Salvador"
              "apellidos" => "Tranche"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699514053919"
        "doi" => "10.3265/Nefrologia.pre2014.Feb.12455"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699514053919?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053916?idApp=UINPBA000064"
    "url" => "/20132514/0000003400000002/v0_201502091616/X2013251414053916/v0_201502091616/en/main.assets"
  ]
  "itemAnterior" => array:17 [
    "pii" => "X2013251414053736"
    "issn" => "20132514"
    "doi" => "10.3265/Nefrologia.pre2013.Dec.12303"
    "estado" => "S300"
    "fechaPublicacion" => "2014-03-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia &#40;English Version&#41;. 2014;34:230-4"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 6852
      "formatos" => array:3 [
        "EPUB" => 344
        "HTML" => 5702
        "PDF" => 806
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "titulo" => "Acute rejection of non-functional renal grafts in dialysis patients after starting treatment with interferon and ribavirin"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "230"
          "paginaFinal" => "234"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Rechazo agudo del injerto renal no funcionante en pacientes en di&#225;lisis despu&#233;s de iniciar tratamiento con interfer&#243;n y ribavirina"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig1"
          "etiqueta" => "Tab.  1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "copyright" => "Elsevier Espa&#241;a"
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "12303_16025_56345_en_t1_12.12303i4_copy1.jpg"
              "Alto" => 742
              "Ancho" => 2146
              "Tamanyo" => 241229
            ]
          ]
          "descripcion" => array:1 [
            "en" => "Previous experience&#46;"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Teresa Cavero-Escribano, Enrique Morales-Ruiz, M&#46; Teresa Manzano-Pe&#241;a, Raquel Mu&#241;oz-G&#243;mez, Eduardo Hern&#225;ndez-Mart&#237;nez, Eduardo Guti&#233;rrez-Mart&#237;nez, Manuel Praga-Terente"
          "autores" => array:7 [
            0 => array:2 [
              "nombre" => "Teresa"
              "apellidos" => "Cavero-Escribano"
            ]
            1 => array:2 [
              "nombre" => "Enrique"
              "apellidos" => "Morales-Ruiz"
            ]
            2 => array:2 [
              "nombre" => "M&#46; Teresa"
              "apellidos" => "Manzano-Pe&#241;a"
            ]
            3 => array:2 [
              "nombre" => "Raquel"
              "apellidos" => "Mu&#241;oz-G&#243;mez"
            ]
            4 => array:2 [
              "nombre" => "Eduardo"
              "apellidos" => "Hern&#225;ndez-Mart&#237;nez"
            ]
            5 => array:2 [
              "nombre" => "Eduardo"
              "apellidos" => "Guti&#233;rrez-Mart&#237;nez"
            ]
            6 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "Praga-Terente"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699514053739"
        "doi" => "10.3265/Nefrologia.pre2013.Dec.12303"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699514053739?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053736?idApp=UINPBA000064"
    "url" => "/20132514/0000003400000002/v0_201502091616/X2013251414053736/v0_201502091616/en/main.assets"
  ]
  "en" => array:15 [
    "idiomaDefecto" => true
    "titulo" => "Treatment of vascular access-related steal syndrome by means of juxta-anastomotic vein interposition of a prosthetic graft segment"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "235"
        "paginaFinal" => "242"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "Gaspar Mestres, N&#233;stor Fontser&#233;, Ram&#243;n Bofill, C&#233;sar Garc&#237;a-Madrid, Nicol&#225;s Garc&#237;a-Ortega, Fredy Rojas, Marta Barrufet, Vicente Riambau"
        "autores" => array:8 [
          0 => array:3 [
            "nombre" => "Gaspar"
            "apellidos" => "Mestres"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "N&#233;stor"
            "apellidos" => "Fontser&#233;"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "affb"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Ram&#243;n"
            "apellidos" => "Bofill"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "C&#233;sar"
            "apellidos" => "Garc&#237;a-Madrid"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Nicol&#225;s"
            "apellidos" => "Garc&#237;a-Ortega"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Fredy"
            "apellidos" => "Rojas"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "Marta"
            "apellidos" => "Barrufet"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "affd"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "Vicente"
            "apellidos" => "Riambau"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:4 [
          0 => array:3 [
            "entidad" => "Unidad Funcional de Acceso Vascular. Sección de Cirugía Vascular. Servicio de Cirugía Cardiovascular. Instituto Clínico del Tórax, Hospital Clínic. UB., Barcelona,   "
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "affa"
          ]
          1 => array:3 [
            "entidad" => "Unidad Funcional de Acceso Vascular. Servicio de Nefrología, Hospital Clínic. UB., Barcelona,   "
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "affb"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Angiología, Cirugía Vascular y Endovascular, Hospital Vall d'Hebron. UAB., Barcelona,   "
            "etiqueta" => "<span class="elsevierStyleSup">c</span>"
            "identificador" => "affc"
          ]
          3 => array:3 [
            "entidad" => "Unidad Funcional de Acceso Vascular. Servicio de Angiorradiología, Hospital Clínic. UB., Barcelona,   "
            "etiqueta" => "<span class="elsevierStyleSup">d</span>"
            "identificador" => "affd"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Tratamiento del s&#237;ndrome de robo del acceso vascular mediante interposici&#243;n yuxtaanastom&#243;tica de un segmento prot&#233;sico"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:8 [
        "identificador" => "fig1"
        "etiqueta" => "Tab.  1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "12262_16025_56446_en_t1_13.12262_032.jpg"
            "Alto" => 519
            "Ancho" => 2150
            "Tamanyo" => 190649
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Description of the types of arteriovenous accesses addressed in the series&#46;"
        ]
      ]
    ]
    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Arteriovenous fistula &#40;AVF&#41; is the method of choice for vascular access during haemodialysis sessions in patients with end-stage renal failure&#44; because&#44; compared with prosthetic arteriovenous or central venous catheters&#44; it is associated with lower complication rates&#46;<span class="elsevierStyleSup">1&#44;2</span> However&#44; there is a specific complication of AVF or prosthetic grafts that can be severe and even jeopardize the viability of the affected limb&#58; steal syndrome&#46;</p><p class="elsevierStylePara">Steal syndrome is caused by a decrease in distal blood perfusion due to a proximal preferred blood flow outlet through the vascular access vein&#44; with less resistance than the distal arterial bed&#46;<span class="elsevierStyleSup">3</span> Despite being a physiological phenomenon observed in up to 73&#37; of AVFs and 91&#37; of prostheses &#40;steal syndrome grade I&#41;&#44;<span class="elsevierStyleSup">4</span> it can cause symptoms in up to 8&#37; of accesses<span class="elsevierStyleSup">5</span>&#58; pain during dialysis &#40;grade II&#41;&#44; pain at rest &#40;grade III&#41; or ulceration and necrosis &#40;grade IV&#41;&#46;<span class="elsevierStyleSup">6</span> When these symptoms occur&#44; especially grades III and IV&#44; endovascular or surgical procedures are required to restore distal blood flow and prevent irreversible injury or amputation&#44; maintaining patency and the use of the vascular access&#44; if possible&#46;</p><p class="elsevierStylePara">The treatments proposed for steal syndrome include a variety of techniques&#58; ligature &#40;usually effective&#44; but resulting in access loss&#41;&#44; repair of associated arterial lesions proximal or distal<span class="elsevierStyleSup">7</span>&#44; ligature of the distal radial artery &#40;DRAL&#41;<span class="elsevierStyleSup">8</span> or proximal vascular access &#40;PRAL&#41;<span class="elsevierStyleSup">9</span> in steal cases at the palmar arch in distal cephalic fistulae&#44; proximalisation or distalisation of the anastomosis &#40;PAVA and RUDI&#41;<span class="elsevierStyleSup">10&#44;11</span>&#44; flow reduction techniques &#40;such as banding&#44; with unpredictable results if performed without intraoperative monitoring&#44; or variants of it&#44; such as MILLER<span class="elsevierStyleSup">12</span>&#44; external banding with prosthetic bands<span class="elsevierStyleSup">13&#44;14 </span>or simple ligature of non-useful collateral veins<span class="elsevierStyleSup">15&#44;16</span>&#41;&#44; or DRIL<span class="elsevierStyleSup">3&#44;17</span> &#40;distal revascularization by interposition of an arterial bypass and ligature of the native artery&#41;&#46; The results offered by these techniques are variable&#44; maintaining access and resolving ischemic symptoms in up to 77&#37; of cases treated with DRIL&#46; However&#44; many of them are complex and induce morbidity&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The aim of this study is to present the initial results of a simple and effective technique to treat steal syndrome&#58; reduction of vascular access flow &#40;and increased distal arterial perfusion&#41; by interposing a prosthetic graft segment in the juxta-anastomotic vein&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Our vascular access unit &#40;UFAV&#44;<span class="elsevierStyleItalic"> Hospital Cl&#237;nic&#44; Universidad de Barcelona&#59; Barcelona&#44;</span> Spain&#41; offers a multidisciplinary approach to patients requiring vascular access for haemodialysis&#44; and is a referral centre for patients in our health district and other centres with regards to creation and repair of vascular access&#46; All patients evaluated and treated by our unit are systematically entered prospectively into a multidisciplinary database&#44; which collects basic data&#44; comorbidities&#44; previous vascular accesses&#44; a detailed history and physical and routine ultrasound examinations&#46; All surgical procedures are also noted&#44; once again with a physical examination and intraoperative and immediate postoperative results as also postoperative follow-up&#46;</p><p class="elsevierStylePara">For this study&#44; we included all patients that came to our unit between 2009 and 2012 for symptomatic steal syndrome secondary to a native arteriovenous vascular access performed in our unit or in other centres&#46; Symptomatic steal syndrome was defined as pain at dialysis&#44; constant pain or ulceration &#40;grades II&#44; III and IV&#41; in the hand or forearm of the vascular access&#44; usually associated with other signs of hand ischemia &#40;pallor&#44; coldness&#41; and after ruling out other differential diagnoses by physical examination and selective complementary examinations &#40;carpal tunnel syndrome&#44; joint pain&#44; high venous pressure&#44; etc&#46;&#41;&#46;</p><p class="elsevierStylePara">During the study period&#44; our unit evaluated 51 patients with persistent symptomatic steal syndrome&#46; After an individual assessment and discussion of each case&#44; a physical examination&#44; routine ultrasound&#44; and selective angio-radiological study&#44; we excluded from the series renal transplant patients with normally functioning kidneys &#40;they underwent access ligature&#41;&#44; subsidiary accesses to be repaired with other techniques &#40;proximal or distal arterial stenosis treated with endovascular procedures&#44; distal accesses treated by DRAL&#44; simple ligature of useless venous collaterals in proximal accesses&#41;&#44; useless accesses&#44; presence of severe distal artery diseases&#44; those cases associated with very extensive ulcerated lesions&#44; poor health conditions or patient preference&#46;</p><p class="elsevierStylePara">In brachio-basilic side to side fistulae with several output drainage veins &#40;basilic&#44; elbow perforating and&#47;or cephalic vein&#41;&#44; we chosed to perform a simple ligature of useless venous collaterals when the diameter of one of these was greater than 4 mm&#44; and to add a prosthetic interposition to the useful vein &#40;in addition to useless collaterals ligature&#41; when said collaterals were all smaller&#46; We dismissed making this decision based on flow&#44; given the difficulty and unreliability of calculating this with ultrasounds&#44; especially for the perforating elbow vein&#46;</p><p class="elsevierStylePara">Finally&#44; 14 cases were included&#44; which were treated with the prosthetic interposition technique&#46; A segment of straight tubular 6 mm prosthesis made of polytetrafluoroethylene &#40;PTFE&#41; graft&#44; 2cm long&#44; was interposed in the juxta-anastomotic venous segment by end to end anastomosis of both venous stumps &#40;Figure 1&#41;&#46; Useless venous collaterals &#40;less than 4mm in diameter&#41; were ligated in side to side brachio-basilic AVF&#44; and when the preoperative study &#40;ultrasound and&#47;or angiography&#41; showed perianastomotic artery stenosis&#44; this was repaired by patch angioplasty&#44; in addition to interposition of the juxta-anastomotic prosthetic segment&#46;</p><p class="elsevierStylePara">In addition to patients&#8217; basic and clinical preoperative&#44; the following were collected in a prospective database&#58;</p><p class="elsevierStylePara">Preoperative Examination&#58; physical exam &#40;grade of steal syndrome&#41;&#44; ultrasound examination &#40;prior vascular access type&#44; location&#44; venous drainage&#44; arterial and venous diameters&#44; systolic&#44; diastolic and mean speeds in the proximal artery &#91;2cm proximal to the anastomosis&#93; and distal radial artery in the wrist&#41;&#46;</p><p class="elsevierStylePara">Intraoperative Examination&#58; procedure performed&#44; immediate physical examination &#40;pulse&#44; palpable thrill&#44; murmur at access&#44; distal arterial pulse&#41; and ultrasound &#40;same preoperative measurements&#41;&#46;</p><p class="elsevierStylePara">Follow-up&#58; postoperative follow-up of clinical symptoms and adequacy of access for haemodialysis sessions&#44; patency and need for secondary procedures&#46;</p><p class="elsevierStylePara">All surgeries and examinations were performed by the same surgeon&#44; using the same ultrasound device&#58; SonoSite MicroMaxx Ultrasound System &#40;Sonosite Inc&#44; WA&#44; USA&#41; and a HFL38&#47;13-6 MHz 38 mm linear array transducer&#44; adjusting and steering the pulsed wave doppler angle to 60&#186; to vessel direction and gate size to vessel diameter&#46; Intra-operative measurements were recorded in the operating room&#44; during surgery and after anastomosis creation&#59; aseptic conditions were taken into account&#46; These measurements were not considered in surgery decisions&#46; Velocities &#40;PSV&#44; EDV&#44; MV&#41; and RI were automatically calculated&#44; and vessel diameter &#40;adventitia-adventitia&#41; was manually measured&#46; Flows &#40;mL&#47;min&#41; were calculated using manufacturer proposed parameters&#58; cross sectional area &#40;0&#46;785xD<span class="elsevierStyleInf">2</span>&#44; in cm<span class="elsevierStyleSup">2</span>&#41; x time averaged mean velocity &#40;MV&#44; in cm&#47;s&#41; x conversion factor &#40;0&#46;06&#41;&#46; All pre- and intra-operative measurements were always taken in the same place&#46;Vascular access flow was estimated according to the flow of the proximal artery as the most reliable method&#44;<span class="elsevierStyleSup">18&#44;19</span> dismissing vein flow rates &#40;less reliable<span class="elsevierStyleSup">18&#44;19</span> and as several draining veins exist which in many cases affect this interpretation&#41;&#46; Total distal arterial perfusion flow was not calculated&#44; because there are several drainage distal arteries &#40;radial&#44; ulnar&#44; interosseous&#41; that should be added and due to the technical and computer complexity that this entails&#44; in spite of&#44; changes in distal radial artery flow were calculated and considered an estimate of overall changes in distal perfusion&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistics</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Frequency and descriptive statistics were obtained&#44; and comparisons were performed using SPSS software&#44; version 19&#46;0&#44; describing medians and ranges or interquartile ranges &#40;25-75 percentiles&#41; and percentages&#46; Changes in flows were defined as percentages of change &#40;&#91;preoperative-postoperative&#93;&#47;preoperative&#41;&#44; and were described as medians and interquartile ranges&#46; Statistical differences between groups were evaluated using the Wilcoxon signed rank test for comparisons of pre-postoperative flows&#46; Measures of time to event were analyzed using Kaplan- Meier survival analysis&#44; with estimated percentages at 12 and 24 months&#46; A P value &#60;&#46;05 was considered to be statistically significant&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The 14 patients included in this study &#40;57&#37; male&#44; median age 72 years&#41; had a high percentage of comorbidities &#40;86&#37; hypertension&#44; 78&#37; smoking history&#44; 71&#37; dyslipidaemia&#44; 57&#37; ischaemic heart disease&#44; 43&#37; diabetes mellitus&#44; 29&#37; severe symptomatic peripheral artery disease&#44; 21&#37; chronic obstructive pulmonary disease&#41;&#46; All were on renal replacement therapy by hemodialysis for a median of 1&#46;1 years &#40;range 0&#46;2 to 5&#46;1&#41;&#44; although the actual arteriovenous access was made 1&#46;5 years earlier &#40;range 0&#46;1 to 12&#46;7&#41;&#44; it was a secondary access in 50&#37; of cases&#46; All had symptomatic steal syndrome &#40;grade II&#58; 2&#44; grade III&#58; 8&#44; grade IV&#58; 4&#41;&#46;</p><p class="elsevierStylePara">Original AVF accesses are described in Table 1&#46; All of them were proximal fistulae with a cephalic or basilic drainage vein&#44; or both&#46; As has already been described in side to side brachio-basilic fistulae the elbow perforating vein or other useless veins &#40;proximal basilic or cephalic&#41; were occluded or were under 4mm in diameter&#46; 71&#37; of accesses were in the left arm&#46;</p><p class="elsevierStylePara">All cases were treated using the juxta-anastomotic prosthetic interposition technique &#40;described above&#41;&#46; Arterial anastomotic stenoses were diagnosed in 2 cases and repaired by an additional arterial patch angioplasty&#46; In the 8 cases of side to side&#44; brachio-basilic arteriovenous fistulae&#44; we also carried out a ligature of small useless collateral veins &#40;perforating veins or proximal basilic of less than 4mm in diameter&#41;&#44; and in 5 we performed a superficial transposition of the proximal basilic vein&#46; All cases were performed under local or regional anaesthesia and as hospital outpatients without hospital admittance&#46;</p><p class="elsevierStylePara">The technical success of the procedure was 100&#37;&#46; Pre- and postoperative ultrasonography showed immediate access flow reduction of 39&#37; &#40;proximal arterial flow&#41; and an increase in the flow of the distal radial artery of 477&#37; &#40;Table 2&#41;&#46;</p><p class="elsevierStylePara">Ischaemic symptoms completely disappeared and ischaemic lesions healed following the prosthetic interposition technique in 12 cases &#40;86&#37;&#44; Figure 2&#41;&#46; However&#44; the other two cases showed partial improvement with persistent ischemic pain&#44; eventually requiring access ligature within three months of follow up&#46; Technical failure was attributed to a proximal arterial stenosis not initially diagnosed and to an artery of small calibre and low flow&#46; Both cases&#44; after initial repair&#44; had the lowest increase in distal blood flow and access flow decrease in all the series&#46; The postoperative complication occurred due to rupture of an excessively dilated basilic vein that had undergone superficial transposition&#44; three days after the initial procedure&#44; which required a permanent access ligature&#46; There were no minor or major amputations in any case after surgery or during follow-up&#46;</p><p class="elsevierStylePara">Mean follow-up was 12&#46;04 months &#40;range 0&#46;2 to 33&#46;5&#41;&#46; There were no losses to follow-up&#44; there were no new ischaemic symptoms&#44; or access thrombosis and only one reintervention &#40;balloon angioplasty&#41; performed because of stenosis of the interposed prosthesis during follow up&#46; Therefore&#44; primary&#44; assisted primary and secondary patency free from ischaemic symptoms were 78&#37;&#44; 78&#37; and 78&#37; at 12 months and 62&#37;&#44; 78&#37; and 78&#37; at 24 months&#44; respectively &#40;Figure 3&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Steal syndrome is caused by a decrease in distal blood perfusion due to a proximal preferred blood flow outlet through the vascular access vein&#44; with less resistance than the distal arterial bed&#46;<span class="elsevierStyleSup">3</span> Some cases of steal syndrome can be repaired with specific treatments &#40;proximal or distal arterial stenosis can usually be treated with endovascular techniques&#44; steal syndromes in radio-cephalic fistulae due to palmar arch steal can be repaired by DRAL<span class="elsevierStyleSup">8</span> or other syndromes of excess venous output due to large collaterals can be treated with simple non-useful vein ligatures<span class="elsevierStyleSup">15&#44;16</span>&#41;&#46;</p><p class="elsevierStylePara">However&#44; in many cases of proximal accesses without arterial lesions or large useless collateral veins&#44; steal syndrome is directly due to excess flow from the artery to the venous outflow to the detriment of the distal arterial system&#46; In these cases&#44; the treatment proposed by our group &#40;the juxta-anastomotic vein interposition of a prosthetic 6mm graft segment&#44; with selective repair of arterial stenoses with patch angioplasty and ligature of useless collateral veins&#41; partially reverses this condition reducing the overall fistula flow and increasing distal blood perfusion&#46; These flow changes have been seen by echographic measurement&#46; Overall reduction of access flow by 39&#37; and increase in distal radial artery flow in 477&#37; &#40;it therefore follows that there is a reduction in access flow at the expense of a reduction in venous outflow&#44; thereby increasing distal arterial blood perfusion&#41;&#46; Furthermore&#44; results at two years follow-up are promising &#40;assisted primary and secondary patency 78&#37;&#41;&#46;</p><p class="elsevierStylePara">Prosthetic interposition technique is a flow reduction technique &#40;a variant of classical banding&#44; but controlling diameter and length&#41;&#44; thus increasing distal arterial perfusion pressure&#46; Other flow reduction techniques have been effective&#44; but have unpredictable results&#46; The most widely used world-wide is banding&#44; which is a partial ligature of the juxta-anastomotic vein&#46; Although effective in some cases&#44; it has been related to non-consistent results and high failure rates due to excessively tight or loose ligatures&#46; To ensure ligature diameter&#44; techniques such as MILLER banding have been designed &#40;ensuring ligature diameter with an endoluminal ball&#41;&#44;<span class="elsevierStyleSup">12</span> banding assisted by a dilator<span class="elsevierStyleSup">20</span> or monitored intraoperatively with flow and digital pressure measurements&#44;<span class="elsevierStyleSup">21</span> thus obtaining better results&#46; The use of prosthetic segments as external banding&#44; to reduce vein diameter<span class="elsevierStyleSup">13&#44;14&#44; </span>has also shown better results than usual banding&#44; however&#44; depending on vein diameter&#44; there are concerns with regards to the risk of stenosis and thrombosis due to excess intra-banding fold tissue&#46;</p><p class="elsevierStylePara">Other techniques such as PAVA or RUDI<span class="elsevierStyleSup">10&#44;11</span> or interposition of long loop prosthetic segments<span class="elsevierStyleSup">22</span> are more complex procedures&#44; which use longer prosthetic segments and have an increased risk of thrombosis&#44; but have the same objective as the procedure presented&#58; to reduce access flow by reducing vessel diameter to that of the interposed prosthetic segment&#44; and therefore the same result is obtained&#46;</p><p class="elsevierStylePara">The most commonly used technique to treat steal syndrome is probably DRIL<span class="elsevierStyleSup">3&#44;17</span>&#58; using a humeral-humeral arterial bypass proximally to distally of the arteriovenous anastomosis &#40;usually with a segment of saphenous vein&#41; plus ligature of the native artery &#40;between the original fistula and distal bypass anastomosis&#41;&#46; Thus&#44; native artery from the origin of the bypass to the arteriovenous anastomosis &#40;of smaller diameter than the bypass&#44; and especially and definitely smaller diameter than the outflow vein&#41; acts like a stenosis with regards to venous outflow&#46; From this perspective&#44; and in spite of other less understandable haemodynamic explanations&#44; DRIL achieves the same objective as prosthetic interposition&#58; it causes a decrease in the size of the vessel connecting the arterial system to the venous outflow &#40;in DRIL&#58; the native artery&#44; and in the interposition technique&#58; a prosthetic segment&#41;&#44; to produce a decreased flow from the proximal artery to the vein and increase distal arterial blood flow&#46; However&#44; DRIL uses a more complex technique with greater morbidity than the interposition technique for the same purpose&#44; with the risk that bypass complications may cause arm ischaemia&#46;<span class="elsevierStyleSup">3</span> In the interposition technique&#44; procedure occlusion only affects arteriovenous access and not arm viability&#46; Furthermore&#44; DRIL has achieved a percentage of early successes and patency close to 77&#37;&#44; similar to the prosthetic interposition technique&#46;</p><p class="elsevierStylePara">The three initial complications that occurred in our series could probably have been avoided&#46; To superficially transpose an excessively dilated vein increases the risk of bleeding and should not have been performed&#44; but instead replaced with a prosthetic access&#46; A diagnostic error was responsible for not diagnosing proximal arterial stenosis&#44; which might have been previously treated and so made it possible to avoid prosthetic interposition&#46; And in arteries of small calibre repairs should be performed with smaller diameter prostheses &#40;4mm&#41;&#46;</p><p class="elsevierStylePara">Fistula ultrasound and compression studies showed two cases of arterial stenosis in the distal segment of the original anastomosis&#46; These cases required&#44; in addition to prosthetic interposition&#44; repair by means of an arterial patch angioplasty&#46; Possibly these would have been good candidates for repair using DRIL&#44; saving the arterial stenosis with a bypass&#44; but with this technique both defects were treated&#58; the arterial stenosis and excess vein output flow&#46; Other procedures&#44; such as ligature of useless collateral veins or superficial transposition of a proximal basilic vein are important to complete flow reduction and increase the usefulness of the final access&#46;</p><p class="elsevierStylePara">As previously described&#44; in side to side brachio-basilic fistulae with useless collateral vein drainage &#40;proximal basilic or elbow perforating veins&#41;&#44; a simple ligature of these may be sufficient to resolve steal syndrome&#46;<span class="elsevierStyleSup">15</span> But given our previous bad experience with this technique and the difficulty and unreliability when calculating collateral flow with echo-Doppler&#44; especially for perforating elbow vein &#40;hard to measure or selectively compress&#41;&#44; we chose to ligate said collateral when they were patent and greater than 4mm diameter&#46; Only when these were smaller&#44; did we add the prosthetic interposition technique to ligature&#44; since simple ligature could be responsible for procedure failure due to insufficient reduction of access flow&#46; Maybe in the future&#44; following the results presented&#44; ultrasound monitoring of intraoperative pre and post ligature flows of simple collaterals &#40;rather than their diameter or systematic simple ligature and clinical follow-up&#41; could help define what side to side accesses require performance of the prosthetic interposition technique&#46;</p><p class="elsevierStylePara">For this study a portable conventional duplex device for morphologic and flow diameters was used&#46; Despite being very useful&#44; easy to use even under intraoperative conditions and available in most services&#44; estimated flows may be higher and there is a low correlation with other more reliable techniques &#40;ultrasound dilution rate or quantitative speed colour indices&#41;&#59; the reason is probably the high susceptibility of conventional Doppler to turbulent flows&#46;<span class="elsevierStyleSup">23</span> Precisely for this reason&#44; many groups recommend measuring flow in the proximal artery as an estimate of the extent of access flow&#44; avoiding vein measurements&#58; this bears a better relationship to access flow&#44; has a more laminar flow&#44; with a regular wall&#44; circular area and is more difficult to compress with the probe&#46;<span class="elsevierStyleSup">18&#44;19</span> This was the reason for estimating arteriovenous access flow by proximal arterial flow&#46;</p><p class="elsevierStylePara">There are several limitations to the validity of our study&#58; it is a short series&#44; without a control group&#44; in which comparisons are difficult&#44; and ultrasound measurements may have system errors&#46; Moreover&#44; as already discussed&#44; in some cases in the series simple ligature of collateral veins could have been an alternative treatment to interposition plus collateral ligature&#46;</p><p class="elsevierStylePara">In conclusion&#44; the interposition of a prosthetic graft segment in the juxta-anastomotic vein&#44; with selective repair of arterial stenosis with patch angioplasty and ligature of useless venous collaterals&#44; can effectively treat symptomatic steal syndrome caused by an arteriovenous vascular access&#44; increasing distal arterial perfusion and reducing the access flow&#46; Despite some avoidable mistakes in our series&#44; this technique is promising at two years follow-up&#46; Its possible indications are symptomatic steal syndromes &#40;grade II to IV&#41; in proximal arteriovenous accesses without associated proximal arterial lesions or large patent useless venous collaterals&#44; and demonstrated hyperflow&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12262&#95;16025&#95;56446&#95;en&#95;t1&#95;13&#46;12262&#95;032&#46;jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56446_en_t1_13.12262_032.jpg" alt="Description of the types of arteriovenous accesses addressed in the series&#46;"></img></a></p><p class="elsevierStylePara">Table 1&#46; Description of the types of arteriovenous accesses addressed in the series&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12262&#95;16025&#95;56447&#95;en&#95;t2&#95;13&#46;12262&#95;03&#46;jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56447_en_t2_13.12262_03.jpg" alt="Comparison of pre and post operative flows in the proximal humeral artery and distal radial artery &#40;medians and interquartile ranges&#44; and&#37; of change&#41;"></img></a></p><p class="elsevierStylePara">Table 2&#46; Comparison of pre and post operative flows in the proximal humeral artery and distal radial artery &#40;medians and interquartile ranges&#44; and&#37; of change&#41;</p><p class="elsevierStylePara"><a href="grande&#47;12262&#95;16025&#95;56448&#95;en&#95;f113&#46;12262&#95;03&#46;jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56448_en_f113.12262_03.jpg" alt="Intraoperative images of the interposition of a prosthetic segment &#44; one &#40;B&#41; with additional ligature of non-useful collateral veins &#40;proximal basilic vein&#41;&#46; "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Intraoperative images of the interposition of a prosthetic segment &#44; one &#40;B&#41; with additional ligature of non-useful collateral veins &#40;proximal basilic vein&#41;&#46; </p><p class="elsevierStylePara"><a href="grande&#47;12262&#95;16025&#95;56449&#95;en&#95;f213&#46;12262&#95;03&#46;jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56449_en_f213.12262_03.jpg" alt=" Ischaemic lesion in 5th finger of the hand&#44; secondary to a steal syndrome due to a brachio-cephalic arteriovenous fistula &#40;A&#41;&#59; improvement of lesion 2 weeks after repair using the interposition graft technique &#40;B&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Ischaemic lesion in 5th finger of the hand&#44; secondary to a steal syndrome due to a brachio-cephalic arteriovenous fistula &#40;A&#41;&#59; improvement of lesion 2 weeks after repair using the interposition graft technique &#40;B&#41;&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12262&#95;16025&#95;56450&#95;en&#95;f3&#95;13&#46;12262&#95;03&#46;jpg" class="elsevierStyleCrossRefs"><img src="12262_16025_56450_en_f3_13.12262_03.jpg" alt="Kaplan-Meier survival function&#46;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Kaplan-Meier survival function&#46;</p>"
    "pdfFichero" => "P1-E567-S4556-A12262-EN.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "es" => array:4 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec438849"
          "palabras" => array:1 [
            0 => "Robo"
          ]
        ]
        1 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec438851"
          "palabras" => array:1 [
            0 => "Complicaciones"
          ]
        ]
        2 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec438853"
          "palabras" => array:1 [
            0 => "Hemodi&#225;lisis"
          ]
        ]
        3 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec438855"
          "palabras" => array:1 [
            0 => "F&#237;stula arterio-venosa"
          ]
        ]
      ]
      "en" => array:4 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec438850"
          "palabras" => array:1 [
            0 => "Vascular access-related steal syndrome"
          ]
        ]
        1 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec438852"
          "palabras" => array:1 [
            0 => "Complications"
          ]
        ]
        2 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec438854"
          "palabras" => array:1 [
            0 => "Haemodialysis"
          ]
        ]
        3 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec438856"
          "palabras" => array:1 [
            0 => "Arteriovenous fistula"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:1 [
        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Objetivos&#58; </span>El s&#237;ndrome de robo es una complicaci&#243;n grave del acceso vascular&#46; Nuestro objetivo es presentar los resultados iniciales de un tratamiento simple y eficaz&#58; la interposici&#243;n de un segmento prot&#233;sico en la vena yuxtaanastom&#243;tica&#46; <span class="elsevierStyleBold">M&#233;todos&#58;</span> Entre 2009 y 2012&#44; 14 pacientes &#40;57&#160;&#37; varones&#44; edad media 71 a&#241;os&#41; con s&#237;ndrome de robo severo por un acceso vascular nativo &#40;grados II-IV&#41;&#44; y tras un estudio cl&#237;nico y ecogr&#225;fico sistem&#225;tico&#44; y angiogr&#225;fico selectivo&#44; fueron tratados mediante la interposici&#243;n de un segmento de pr&#243;tesis tubular&#44; politetrafluoroetileno &#40;PTFE&#41; de 6 mm de di&#225;metro en la vena yuxtaanastom&#243;tica&#44; m&#225;s reparaci&#243;n selectiva de estenosis arterial mediante parche &#40;2 casos&#41; o ligadura de colaterales venosas no &#250;tiles &#40;8 casos&#41;&#46; Se utiliz&#243; anestesia local o regional y un r&#233;gimen ambulatorio en todos los casos&#46; <span class="elsevierStyleBold">Resultados&#58;</span> El &#233;xito t&#233;cnico fue del 100&#160;&#37;&#46; El estudio ecogr&#225;fico pre y posoperatorio mostr&#243; una reducci&#243;n del flujo posoperatorio del acceso del 39&#160;&#37; y un aumento del flujo arterial radial del 477&#160;&#37;&#46; Los s&#237;ntomas isqu&#233;micos se resolvieron en 12 pacientes &#40;86&#160;&#37;&#41;&#59; los otros dos requirieron procedimientos adicionales por s&#237;ntomas isqu&#233;micos persistentes&#46; Ocurri&#243; una ruptura venosa posoperatoria&#44; que requiri&#243; una ligadura definitiva&#46; Ning&#250;n caso sufri&#243; amputaciones ni hubo p&#233;rdidas ni trombosis del acceso en el seguimiento&#46; Las permeabilidades primaria y primaria asistida libres de nuevos s&#237;ntomas isqu&#233;micos fueron del 78&#160;&#37; y del 78&#160;&#37; a los 12 meses&#44; y del 62&#160;&#37; y del 78&#160;&#37; a los 24 meses&#46; <span class="elsevierStyleBold">Conclusiones&#58; </span>La interposici&#243;n de un segmento prot&#233;sico yuxtaanastom&#243;tico es una t&#233;cnica sencilla&#44; r&#225;pida y eficaz en el tratamiento del s&#237;ndrome de robo vascular&#44; con resultados prometedores a dos a&#241;os de seguimiento&#46;</p>"
      ]
      "en" => array:1 [
        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Objective&#58;</span><span class="elsevierStyleBold"> </span>Steal syndrome is a severe complication of vascular access&#46; Our aim is to present the initial results of a simple and effective treatment&#58; the interposition of a prosthetic segment in the juxta-anastomotic vein&#46; <span class="elsevierStyleBold">Method&#58;</span><span class="elsevierStyleBold"> </span>Between 2009 and 2012&#44; 14&#160;patients &#40;57&#160;&#37; male&#44; average age&#160;71&#41; with severe steal syndrome due to vascular access &#40;stages&#160;II-IV&#41;&#44; following a clinical and systematic echographic study and a selective angiographic study&#44; were treated through the interposition of a 6&#160;mm segment of PTFE in the juxta-anastomotic vein&#44; in addition to selective patch repair of arterial stenosis &#40;2&#160;cases&#41; or ligature of useless venous collaterals &#40;8&#160;cases&#41;&#46; Local or regional anaesthesia was used and outpatient care was given in all cases&#46; <span class="elsevierStyleBold">Results&#58;</span><span class="elsevierStyleBold"> </span>There was 100&#160;&#37; technical success&#46; The pre- and post-operative echographical study showed a reduction of post-operative access flow by 39&#160;&#37; and an increase of radial artery flow by 477&#160;&#37;&#46; Ischaemic symptoms were resolved in 12&#160;patients &#40;86&#160;&#37;&#41;&#59; the other two patients required additional procedures due to persistent ischaemic symptoms&#46; There was a post-operative venous rupture&#44; which required a definitive ligation&#46; No patient suffered amputations&#44; nor were there losses or access thrombosis during the follow-up&#46; The primary and primary-assisted patencies free of new ischemic symptoms were 78&#160;&#37; and 78&#160;&#37; at 12&#160;months&#44; and 62&#160;&#37; and 78&#160;&#37; at 24&#160;months&#46; <span class="elsevierStyleBold">Conclusions&#58;</span><span class="elsevierStyleBold"> </span>The interposition of a prosthetic segment in the juxta-anastomotic vein is a simple&#44; quick and effective technique in the treatment of vascular steal syndrome&#44; with promising results at the 2&#160;year follow-up&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:8 [
        "identificador" => "fig1"
        "etiqueta" => "Tab.  1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "12262_16025_56446_en_t1_13.12262_032.jpg"
            "Alto" => 519
            "Ancho" => 2150
            "Tamanyo" => 190649
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Description of the types of arteriovenous accesses addressed in the series&#46;"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig2"
        "etiqueta" => "Tab.  2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "12262_16025_56447_en_t2_13.12262_03.jpg"
            "Alto" => 273
            "Ancho" => 2157
            "Tamanyo" => 163532
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Comparison of pre and post operative flows in the proximal humeral artery and distal radial artery &#40;medians and interquartile ranges&#44; and&#37; of change&#41;"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig3"
        "etiqueta" => "Fig. 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "12262_16025_56448_en_f113.12262_03.jpg"
            "Alto" => 348
            "Ancho" => 1010
            "Tamanyo" => 171374
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Intraoperative images of the interposition of a prosthetic segment &#44; one &#40;B&#41; with additional ligature of non-useful collateral veins &#40;proximal basilic vein&#41;&#46;"
        ]
      ]
      3 => array:8 [
        "identificador" => "fig4"
        "etiqueta" => "Fig. 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "12262_16025_56449_en_f213.12262_03.jpg"
            "Alto" => 616
            "Ancho" => 1002
            "Tamanyo" => 237260
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Ischaemic lesion in 5th finger of the hand&#44; secondary to a steal syndrome due to a brachio-cephalic arteriovenous fistula &#40;A&#41;&#59; improvement of lesion 2 weeks after repair using the interposition graft technique &#40;B&#41;&#46;"
        ]
      ]
      4 => array:8 [
        "identificador" => "fig5"
        "etiqueta" => "Fig. 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "12262_16025_56450_en_f3_13.12262_03.jpg"
            "Alto" => 966
            "Ancho" => 2113
            "Tamanyo" => 273183
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Kaplan-Meier survival function&#46;"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliography"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:23 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48 Suppl 1:S176-247. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16813989" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Tordoir J, Canaud B, Haage P, Konner K, Basci A, Fouque D, et al. EBPG on Vascular Access. Nephrol Dial Transplant 2007;22 Suppl 2:ii88-117."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Anaya-Ayala JE, Pettigrew CD, Ismail N, Diez-De Sollano AL, Syed FA, Ahmed FG, et al. Management of dialysis access-associated ¿steal¿ syndrome with DRIL procedure: challenges and clinical outcomes. J Vasc Access 2012;13(3):299-304. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22266588" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Zamani P, Kaufman J, Kinlay S. Ischemic steal syndrome following arm arteriovenous fistula for hemodialysis. Vasc Med 2009;14(4):371-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19808723" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Rocha A, Silva F, Queirós J, Malheiro J, Cabrita A. Predictors of steal syndrome in hemodialysis patients. Hemodial Int 2012;16(4):539-44. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22510166" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Mickley V. Steal syndrome--strategies to preserve vascular access and extremity. Nephrol Dial Transplant 2008;23(1):19-24. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17905806" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Malik J, Tuka V, Kasalova Z, Chytilova E, Slavikova M, Clagett P, et al. Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies. J Vasc Access 2008;9(3):155-66. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18850575" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Miller GA, Khariton K, Kardos SV, Koh E, Goel N, Khariton A. Flow interruption of the distal radial artery: treatment for finger ischemia in a matured radiocephalic AVF. J Vasc Access 2008;9(1):58-63. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18379982" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Bourquelot P, Gaudric J, Turmel-Rodrigues L, Franco G, Van Laere O, Raynaud A. Proximal radial artery ligation (PRAL) for reduction of flow in autogenous radial cephalic accesses for haemodialysis. Eur J Vasc Endovasc Surg 2010;40(1):94-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20359915" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Callaghan CJ, Mallik M, Sivaprakasam R, Iype S, Pettigrew GJ. Treatment of dialysis access-associated steal syndrome with the ¿revision using distal inflow¿ technique. J Vasc Access 2011;12(1):52-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21058261" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Thermann F, Wollert U, Ukkat J, Dralle H. Proximalization of the arterial inflow (PAI) in patients with dialysis access-induced ischemic syndrome: first report on long-term clinical results. J Vasc Access 2010;11(2):143-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20155715" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Miller GA, Goel N, Friedman A, Khariton A, Jotwani MC, Savransky Y, et al. The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome. Kidney Int 2010;77(4):359-66. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20010547" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Smith GE, Barnes R, Green L, Kuhan G, Chetter IC. A ¿christmas tree¿ band for the treatment of arteriovenous dialysis access-related steal syndrome. Ann Vasc Surg 2013;27(2):239.e9-239.e12."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Papalois VE, Haritopoulos KN, Farrington K, Hakim NS. Successful reversal of steal syndrome following creation of arteriovenous fistula by banding with a ringed Gore-Tex cuff: a new technique. Int Surg 2003;88(1):52-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12731732" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Moini M, Rasouli MR, Nouri M. Ligation of the perforating vein: a treatment for steal syndrome in side-to-side elbow arteriovenous fistula. Ann Vasc Surg 2008;22(2):307. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18346584" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Moini M, Williams GM, Pourabbasi MS, Rasouli MR, Tarighi P, Mardanloo A, et al. Side-to-side arteriovenous fistula at the elbow with perforating vein ligation. J Vasc Surg 2008;47(6):1274-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18467069" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Aimaq R, Katz SG. Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation. J Vasc Surg 2013;57:1073-8."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Lomonte C, Casucci F, Antonelli M, Giammaria B, Losurdo N, Marchio G, et al. Is there a place for duplex screening of the brachial artery in the maturation of arteriovenous fistulas? Semin Dial 2005;18(3):243-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15934972" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Wiese P, Nonnast-Daniel B. Colour Doppler ultrasound in dialysis access. Nephrol Dial Transplant 2004;19(8):1956-63. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15199165" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Wang S, Almehmi A, Packer J. Dilator-assisted banding for managing complications associated with excessive hemodialysis access flow. Semin Dial 2013;26(1):100-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22548358" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Van Hoek F, Scheltinga M, Luirink M, Pasmans H, Beerenhout C. Banding of hemodialysis access to treat hand ischemia or cardiac overload. Semin Dial 2009;22(2):204-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19426430" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Henriksson AE, Bergqvist D. Steal syndrome after brachiocephalic fistula for vascular access: correction with a new simple surgical technique. J Vasc Access 2004;5(1):13-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16596533" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Zanen AL, Toonder IM, Korten E, Wittens CH, Diderich PN. Flow measurements in dialysis shunts: lack of agreement between conventional Doppler, CVI-Q, and ultrasound dilution. Nephrol Dial Transplant 2001;16(2):395-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11158420" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/20132514/0000003400000002/v0_201502091616/X2013251414053924/v0_201502091616/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "35448"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Technical Notes"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003400000002/v0_201502091616/X2013251414053924/v0_201502091616/en/P1-E567-S4556-A12262-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053924?idApp=UINPBA000064"
]

Article information

ISSN: 20132514
Original language: English

DOI:10.3265/Nefrologia.pre2014.Jan.12262

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	13	11	24
2024 October	104	52	156
2024 September	99	47	146
2024 August	118	75	193
2024 July	76	37	113
2024 June	104	52	156
2024 May	106	37	143
2024 April	86	46	132
2024 March	73	28	101
2024 February	101	40	141
2024 January	77	31	108
2023 December	67	33	100
2023 November	99	37	136
2023 October	109	50	159
2023 September	140	40	180
2023 August	105	29	134
2023 July	133	39	172
2023 June	56	23	79
2023 May	79	40	119
2023 April	67	22	89
2023 March	99	23	122
2023 February	74	17	91
2023 January	57	21	78
2022 December	110	27	137
2022 November	90	27	117
2022 October	102	52	154
2022 September	80	37	117
2022 August	89	39	128
2022 July	81	62	143
2022 June	104	32	136
2022 May	122	42	164
2022 April	154	76	230
2022 March	180	62	242
2022 February	180	52	232
2022 January	168	42	210
2021 December	103	36	139
2021 November	99	33	132
2021 October	145	43	188
2021 September	125	39	164
2021 August	86	43	129
2021 July	99	27	126
2021 June	99	26	125
2021 May	96	46	142
2021 April	151	54	205
2021 March	109	38	147
2021 February	105	20	125
2021 January	74	23	97
2020 December	65	18	83
2020 November	74	25	99
2020 October	53	22	75
2020 September	82	16	98
2020 August	63	24	87
2020 July	99	20	119
2020 June	62	14	76
2020 May	63	26	89
2020 April	60	21	81
2020 March	70	28	98
2020 February	86	29	115
2020 January	96	28	124
2019 December	95	28	123
2019 November	101	33	134
2019 October	132	628	760
2019 September	177	24	201
2019 August	116	32	148
2019 July	105	28	133
2019 June	145	39	184
2019 May	140	25	165
2019 April	168	20	188
2019 March	66	32	98
2019 February	54	22	76
2019 January	54	25	79
2018 December	135	42	177
2018 November	185	19	204
2018 October	136	22	158
2018 September	145	33	178
2018 August	128	14	142
2018 July	93	17	110
2018 June	88	15	103
2018 May	124	14	138
2018 April	110	19	129
2018 March	106	13	119
2018 February	102	11	113
2018 January	168	12	180
2017 December	196	13	209
2017 November	174	23	197
2017 October	127	11	138
2017 September	149	19	168
2017 August	216	13	229
2017 July	203	12	215
2017 June	204	17	221
2017 May	220	12	232
2017 April	129	15	144
2017 March	128	23	151
2017 February	175	11	186
2017 January	84	7	91
2016 December	116	9	125
2016 November	157	20	177
2016 October	227	12	239
2016 September	316	5	321
2016 August	344	6	350
2016 July	268	14	282
2016 June	190	0	190
2016 May	185	0	185
2016 April	171	0	171
2016 March	131	0	131
2016 February	154	0	154
2016 January	147	0	147
2015 December	150	0	150
2015 November	131	0	131
2015 October	138	0	138
2015 September	164	0	164
2015 August	130	0	130
2015 July	115	0	115
2015 June	57	0	57
2015 May	68	0	68
2015 April	6	0	6

Show all

Indexed in:

Follow us:

Statistics

Indexed in:

Follow us:

Statistics

Subscribe to our newsletter