Modified Miller Banding Procedure for Managing High-flow Access and Dialysis-associated Steal Syndrome

Abstract

Purpose Both high-flow vascular access (VA) and dialysis-associated steal syndrome are serious complications requiring a flow reduction technique. We adopted the minimally invasive limited ligation endoluminal-assisted revision (MILLER) banding procedure with some modifications to control the high blood flow and steal syndrome during VA procedures and retrospectively assessed the outcome. Methods Seven patients with high-flow access (access flow >1400 ml/min) and five patients with steal syndrome (with pain, coldness, or cyanosis) were treated using the MILLER banding method. Flow volume of the brachial artery was monitored using Doppler ultrasonography during the banding procedure. In patients with steal syndrome, the finger probe of a pulse oximeter was attached to a finger on the ipsilateral side, and the peripheral oxygen saturation (SpO2) was monitored. Results In the high-flow group, the mean access blood flow (Qa) decreased from 2043 ± 463 ml/min (mean ± SD) to 1248 ± 388 ml/min (p<0.001). In the steal syndrome group, the SpO2 value improved in all steal syndrome patients after banding. Symptoms were almost relieved in two steal syndrome patients. The Qa in the steal group decreased from 997 ± 867 to 548 ± 376 ml/min (p = 0.12). The secondary patency rates of the high-flow and steal groups at 6 months were 83.3% and 50%, respectively. Conclusions The MILLER banding procedure with intraoperative access flow monitoring is effective to treat high-flow VA and steal syndrome.