Synopsis
Distinguish distal arterial ischaemia caused by dialysis-access steal from venous congestion caused by outflow obstruction, grade urgency from tissue and neurological threat, and preserve both the limb and access where safely possible.
- Steal is distal arterial ischaemia: a cool pale hand, dialysis- or exercise-related pain, rest pain, weakness, sensory loss or tissue loss determines severity and urgency.
- Rest pain, distal ulceration or necrosis is UKKA severe steal and needs prompt perfusion-restoring intervention; access ligation may be the quickest reliable rescue when the hand is threatened.
- Venous hypertension causes warm congested swelling, access pulsatility, prolonged bleeding and collateral veins; whole-arm or chest-wall collaterals suggest central venous stenosis.
Key red flags
Rest pain, ulceration, necrosis, progressive weakness or sensory loss is severe steal and requires prompt treatment rather than conservative observation.
Sudden pain with an absent access thrill suggests acute thrombosis or arterial embolic injury, which needs same-day imaging and vascular review.
Tense arm swelling with neurological deficit, severe pain or rapidly expanding haematoma raises concern for compartment-threatening pressure or bleeding.
Massive venous congestion, threatened skin, access dysfunction or swelling of the face and neck warrants urgent central outflow assessment.
Persistent rest pain, weakness, sensory deficit, ulceration or necrosis indicates threatened tissue or nerve and needs prompt treatment.
Investigation priorities
Compare temperature, colour, capillary refill, pulses, motor and sensory function, skin integrity, swelling, collaterals, thrill and bruit.
Measure access flow and identify inflow stenosis, distal arterial disease, outflow lesions, thrombus and the effect of controlled access compression.
Management branches
Use for rest pain, motor or sensory deficit, ulceration, necrosis or rapidly progressive symptoms in the access hand.
- Stop ongoing dialysis if symptoms are worsening, assess haemodynamic stability and the full neurovascular status, protect the hand and contact vascular-access specialists urgently.
- Use duplex and angiography as the clinical state permits to identify arterial stenosis, access flow and reconstruction options without delaying rescue of a clearly threatened hand.
Use when the hand has coolness alone or exertional or dialysis-related pain without rest pain, neurological deficit or tissue loss.