Hand ischemia: Often we encounter patients who complains of numbness and pain during dialysis in the ipsilateral side of the access; and often diagnose it as steal syndrome; well not entirley true all the time.(70-% of patient have a steal on angiograms without symptoms)
We should all do a detailed history and exam and then think of other common differential before we reach the steal syndrome diagnosis because the steal syndrome indicates a specific management such as ligation of the access.
What is a better term to use is DHIS; distal hypoperfusion ischemia syndrome. important differential diagnosis list below:
CTS, carpal tunnel syndrome; DA, destructive arthropathy; DHIS, distal hypoperfusion ischemic syndrome; IMN, ischemic monomelic neuropathy.
DHIS has multiple causes: Arterial stenosis, vascular steal, and distal arteriopathy as well as combinations of these three; so it is important to visulize the whole access with angiogram including the central vessels to diagnose an arterial stenosis which usally improves after angioplasty and does not need ligation. now important clues are cold extremities on exam and lack of distal pulse. high risk patients are DM, smokers.
The nephrologist should be very involved in the diagnosis phase as well as the management and our role should NOT be just a referral to the vascular suergon.