Dialysis Access-Associated Steal Syndrome in a Hemodialysis Patient: A Case Report

Dialysis access-associated steal syndrome (DASS) is an uncommon but potentially limb-threatening complication of hemodialysis arteriovenous access. DASS results from preferential shunting of arterial blood into the low-resistance access circuit, causing distal hypoperfusion and symptoms ranging from hand coolness and paresthesias to skin ulceration and tissue loss. We discuss the case of a 32-year-old patient with end-stage renal disease on hemodialysis who presented with prolonged bleeding after dialysis from their right upper-extremity arteriovenous fistula. The patient then underwent fistulography with endovascular treatment of venous outflow pathology and pseudoaneurysms. One month later, the patient developed worsening dialysis-associated forearm/hand pain and paresthesias. Repeat angiography demonstrated poor anterograde distal forearm perfusion with flow reversal into the fistula, absence of proximal arterial inflow stenosis, and restoration of distal perfusion with venous outflow compression, supporting the diagnosis of DASS. This case highlights the importance of recognizing dialysis-associated ischemic symptoms while reviewing a mechanism-based diagnostic approach used to guide management.