Current concepts in the pathophysiology and management of arteriovenous access-induced hand ischemia.

The manifestations of hand ischemia because of an arteriovenous access can range from hand pain, tissue necrosis, and loss of the entire hand. Recent data have emphasized that multiple mechanisms (arterial steal, ie, retrograde flow, arterial stenosis, and arterial calcification) are responsible for inducing hand ischemia. Because any or a combination of the 3 mechanisms can lead to peripheral ischemia, distal hypoperfusion ischemic syndrome is a more appropriate term to denote hand ischemia. A detailed history, physical examination, and differential diagnosis form the initial step in the management of distal hypoperfusion ischemic syndrome. A complete arteriogram to evaluate the circulation of the extremity from the aortic arch to the palmar arch is essential. The choice of treatment modality should be based on this evaluation. In this article, we review the pathophysiology and present current strategies to ameliorate distal hypoperfusion ischemic syndrome.