Dermatologic Manifestations and Management of Vascular Steal Syndrome in Hemodialysis Patients With Arteriovenous Fistulas

A 50-year-old man with a history of type 2 diabetes mellitus,coronaryarterydisease,peripheralvasculardisease,and severevascular calcificationunderwentplacementof abrachial artery to antecubital vein arteriovenous fistula (AVF) in his left arm after the diagnosis of end-stage renal disease. He first experiencedhandclaudicationanderythemaofhis left hand and digits 14 months after surgery. Pain and coldnessof the lefthand increasedgraduallyovera4-monthperiod,andweaknesswasnotedonexamination.Vascularsteal created by the fistula was suspected; however, the patient hadahistoryofbilateralulnarneuropathy,carpaltunnelsyndrome,andgeneralizedsensoryaxonalpolyneuropathy.Ligation of the fistula was delayed because no other site was availableforlong-termangioaccess.Thepatientsubsequently began continuous ambulatory peritoneal dialysis. Ischemic ulcers developed at 18 months on the dorsal aspect of the fourth and fifth digits of the left hand. Skin examination revealed black eschars surrounded by an inner zone of white skin and a peripheral zone of red-purple edema.Thenecroticescharscontinuedtoextendproximally onthesecond,fourth,andfifthdigitsofthehand(Figure1). Nineteenmonthsafter the initialaccesssurgery, the leftarm fistula was ligated to eliminate the steal effect. Because of advancedgangrene, thesecond, fourth, and fifthdigits later required amputation at the level of the proximal interphalangeal joint (Figure2). Subsequently, the third distal finger became ischemic and then gangrenous. The patient was referred to dermatology for wound care. His residual digits and the necrotic third-finger wound were packed with damp 25% acetic acid–soaked cotton packing strips (NuGauze; Johnson & Johnson, New Brunswick, NJ) and occluded with polyethylene (Saran) wrap to maintain a moist environment. The third digit was allowed to autoamputate at the proximal interphalangeal joint. Subsequently, the protruding phalanx was removed with a rongeur and treated daily with saline packing until healing was accomplished. Through tissue-conserving wound care management, our patient was able to maintain a functional hand.