Journal of Surgery (ISSN: 2575-9760)

Research Article

The Use of Indocyanine Green Fluorescence Angiography in Predicting Distal Ischemia Following Arteriovenous Fistula Placement

Alexandra Mercel,1 Shiva Gautam,2 Joseph Habib,1 Jon Allmon,1 James W Dennis1*

1Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Jacksonville,


2Department of Medicine, University of Florida, College of Medicine, Jacksonville, USA

Corresponding Author*: James W Dennis, Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Jacksonville, 653 West 8th Street, Jacksonville, FL 32209, USA

Received Date: 13 August, 2021

Accepted Date: 27 August, 2021

Published Date: 01 September, 2021


Objective: Vascular steal syndrome of the distal extremity following Arterio-Venous (AV) fistula placement can occur in up to 2-20% of patients. This occurrence often leads to additional surgery such as the Distal Revascularization with Interval Ligation (DRIL) procedure, or fistula ligation. Although multiple risk factors have been shown to be associated with steal, there currently exists no reliable means by which to predict its development at the time of fistula creation. The purpose of this study was to apply a well-established perfusion measurement examination to the ipsilateral hand at the time of access in order to identify those patients at high risk for steal syndrome.

Methods: Over a three year period (June 2015-June 2018), this study prospectively used indocyanine green fluorescent imaging just prior to and immediately after fistula placement in the OR to test its ability predict steal. This technology is widely used intra-operatively to evaluate perfusion of certain organs (bowel, heart, esophagus, flaps, etc.) to determine perfusion and viability. Multiple points on the ipsilateral hand were imaged just prior to scrubbing the arm and immediately after the dressing was placed. The mean ingress rates of the dye at these points were the primary data points and due to the variability of patients, specifically changes over baseline were specifically studied. The measurements were then correlated clinically with the postoperative outcome. Patients requiring DRIL procedures were separated out at a later date and compared with normal controls.

Results: In 29 consecutive controls with full data, the overall change in the hand perfusion ingress rate after AV fistula placement was 0.17 units/sec or 6%. None of these patients developed vascular steal. Eight patients required a DRIL procedure during the study period. The mean ingress rates pre-operatively between the two groups (5.44 units/sec for controls vs. 5.85 units/ sec for those with steal) were not significantly different (Fisher’s exact test p>0.05). However, the overall mean ingress rate significantly decreased by 2.75 units/sec (46%) in patients with steal (p<0.05). In six of the eight patients undergoing a DRIL procedure, the ingress rate returned to near baseline after DRIL procedure and their symptoms resolved. One patient did not improve by imaging or clinically, and one patient showed a decrease in ingress but improved clinically.

Conclusions: Early data shows indocyanine green fluorescence angiography may be useful in predicting the development of vascular steal following AV fistula placement and the success of DRIL procedures.

Keywords: Fluorescent angiography; Hemodialysis access induced hand ischemia; ICG angiography; Steal syndrome