Recognizing Dialysis Access Steal Syndrome: The Physical Exam as a Critical Diagnostic Tool in Patients on Hemodialysis

Introduction: For patients with end stage renal disease (ESRD) undergoing hemodialysis, arteriovenous fistulas remain the preferred form of vascular access. One of the rare but potentially fatal complications of arteriovenous fistula is the formation of dialysis access steal syndrome (DASS). The incidence of which is reported to be around 8%.1 We report the case of a 72-year-old female with a history of peripheral arterial disease present with dialysis access steal syndrome. Case Description: A 72-year-old woman with a history of end-stage renal disease (ESRD), hypertension, and peripheral arterial disease (PAD) with bilateral kissing iliac stents, currently receiving hemodialysis via a left upper extremity brachiocephalic fistula, presented with progressive pain in the first three digits of her left hand over the past four months. The pain was worsened by activities against gravity and during dialysis sessions. She also reported numbness and a cold sensation in the affected hand. Notably, these symptoms began shortly after undergoing angioplasty of the juxta-anastomotic segment to improve access flow and address difficult cannulation. On physical examination, the modified Allen’s test demonstrated reduced radial artery flow in the left hand. Notably, there were no visible skin changes, grip strength was symmetric, and the reverse Phalen’s test was negative. Arteriogram showed patent vessels but reduced perfusion to the forearm and hand which improved with fistula compression, confirming DASS. She was managed conservatively and referred to vascular surgery for further evaluation. Discussion: DASS still remains a challenging and serious complication associated with arteriovenous fistulas. Age over 60, diabetes, female sex and a brachiocephalic fistula are significant risk factors.1 DASS can be fatal if not identified promptly. Neurologic deficits resulting from ischemia may not be reversible, and patients are at risk of substantial tissue damage or even limb loss.2 This case underscores the importance of maintaining a high index of suspicion and utilizing simple bedside tools—particularly the modified Allen’s test with pulse oximetry—to aid in early detection. Given that DASS symptoms can mimic other neuropathies or ischemic conditions and are often dismissed, a thorough and targeted physical examination is critical.