Trends, outcomes, and factors associated with steal syndrome following creation of arteriovenous hemodialysis access: A safety net hospital system analysis.

Background: Steal syndrome (DASS) is a feared complication of hemodialysis (HD) access creation. There is a paucity of work investigating the relationship between preoperative factors, access type, resource utilization and DASS, particularly within a safety net hospital system.

Methods: A retrospective review of arteriovenous fistula (AVF) or graft (AVG) creation between 2014 and 2019 was conducted from five safety net hospitals. The primary endpoint was the development of DASS within 2 years of HD access creation. Secondary outcomes included reintervention and patency.

Results: There were 1,430 patients, of which 54 (3.8%) developed DASS. The incidence of DASS decreased from 6.3% to 2.2% over the study period. The incidence of DASS was 10.6% for AVG vs 3.5% for AVF (p=0.01). DASS occurred in 5.0% of brachiocephalic and 2.6% of brachiobasilic AVFs. DASS had higher rates of access related ED visits (14.8 vs 4.7%) and reoperation (53.9 vs 12.2%; both p<0.001). Following adjustment, AVG (Adjusted Odds Ratio [AOR] 2.74, 95% Confidence interval [CI] 1.02-7.55) and brachiocephalic AVF (AOR 2.13, CI 1.01-4.52) were associated with higher odds of DASS. Finally, DASS was associated with greater odds of 30-day ED visit for access related complications (AOR 3.36, CI 1.48-7.60) and reoperation (AOR 8.18, CI 4.14-16.18), but there was no significant difference in 12-month patency.

Conclusion: Within a safety net system, the incidence of DASS following AVF/AVG creation is declining. AVG, and brachiocephalic AVF were associated with higher odds of DASS. Finally, DASS was associated with an increased rate of emergency care and reoperation following access creation.