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Minimally Invasive Limited Ligation Endoluminal Revision (MILLER) Of Arteriovenous Fistulas To Correct Steal Syndrome: Results And Clinical Outcomes At One Year

J. Timothy Riley¹, Gregg A Miller², Timothy Wu¹, Rafik Moufid¹, Gaurav Chandra¹, Frank Tarantini¹, William Rodino¹, Thomas Panetta.^1
1Staten Island University Hospital, Staten Island, NY; ²American Access Care, Brooklyn, NY.

OBJECTIVES: Steal syndrome secondary to arteriovenous fistulas (AVFs) occurs in up to 8% of patients. Treatment options include banding, plication, ligation, or distal revascularization interval ligation, DRIL procedure. A minimally invasive procedure utilizing an endoluminal balloon to perform a limited ligation that restricts the venous outflow of the AVF to a known diameter, thereby resolving steal syndrome and preserving the AVF for hemodialysis access is presented.

METHODS: The MILLER procedure was performed on 112 patients, 107 of which presented with steal syndrome and 5 presented with high-output fistulas. The procedure is performed via retrograde sheath inserted into the fistula under fluoroscopy. A 4 mm angioplasty balloon was placed across the arteriovenous anastomosis and inflated to approximately 15 atm. Through two small counter incisions a prolene suture is tunneled around the vein and tied around the vein while the balloon is maintained at full inflation. The outflow is restricted to the exact diameter of the inflated balloon angioplasty catheter. Secondary interventions were performed with either a 3.0 mm or 3.5 mm balloon. Reversal of the steal is documented radiographically and restoration of a distal pulse is documented clinically.

RESULTS: Technical success was 97.3% of AVFs in 112 patients. Three patients could not undergo the procedure because of extensive scarring and/or vein depth. The remaining 109 patients had immediate symptomatic relief and angiographic evidence of reduction in steal syndrome-related flow phenomena, defined as primary success. Of the 109 patients achieving primary success, 10 required secondary interventions for recurrence of steal syndrome symptoms. One patient lost access secondary to infection of the graft.

CONCLUSIONS: The MILLER procedure is a minimally invasive, safe method of salvaging an AVF in patients with symptomatic steal syndrome. Our preliminary data has yielded excellent technical and clinical outcomes with minimal risk to the patient and maintains function of the AVF.