Potential Utility of Hand Acceleration Time in Quantifying the Degree of Malperfusion in Patients With Suspected Hemodialysis Access–Induced Distal Ischemia

Steal phenomenon after upper extremity hemodialysis access is a clinical diagnosis and consists of signs and symptoms ranging from pain during dialysis to tissue loss. Duplex ultrasonography of the access site and limb arterial perfusion often serves as an adjunct to the diagnosis but can have limitations and there is no specific duplex measurement that indicates that an intervention will be a success. We have used hand acceleration time (HAT) to assess perfusion in a number of trauma and shock cases and hypothesized that this approach could also be beneficial in assessing patients with hemodialysis access–induced distal ischemia (HAIDI), both for identifying patients who are candidates for intervention and to measure whether the intervention will be successful. Specifically, we hypothesized that a HAT <100 ms is associated with normal hand perfusion. We performed a retrospective review of 4 patients with upper extremity arteriovenous fistulas who presented with pain and tissue loss involving the ipsilateral hand. In 2 cases, the tissue loss was not primarily due to steal (one due to skin slough from antibiotic reaction and the other due to focal calciphylaxis), and 2 patients had diffuse calcific disease of the forearm arteries. All 4 patients had antegrade flow in the forearm arteries and HAT >100 ms. One patient with soft tissue sloughing was managed with banding of the proximal fistula, and 3 had proximalization of the fistula. All 4 achieved HAT <100 ms and had resolution of symptoms. Hand acceleration time may be a valuable adjunct to determine whether intervention in the setting of hemodialysis access–induced distal ischemia HAIDI may assist with wound healing.