Dialysis-associated steal syndrome with limb ischaemia

Description

A 62-year-old man with end-stage renal failure on dialysis was referred to our hospital with worsening pain and ulceration in his right arm. He was started on haemodialysis 6 months ago, once his newly created brachiocephalic fistula was matured. Previously, he had been on peritoneal dialysis for over 2 years and was transitioned to haemodialysis after multiple catheter-site infections and peritonitis. His medical history was significant for poorly controlled hypertension and hypercholesterolaemia. On physical examination, necrosis of the skin and subcutaneous tissue localised to the right forearm and hand was evident (figure 1), along with dry gangrene of the fourth digit (figure 2). Right radial and ulnar artery pulses were absent. The arm distal to the fistula was cool, with decreased capillary refill and decreased sensation. Continuous handheld Doppler revealed exceptionally low radial and ulnar artery pulse signals and absence of flow at the digital...

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