Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome N. Goel, G.A. Miller,

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Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome N. Goel, G.A. Miller, M.C. Jotwani, J. Licht, I. Schur, W.P. Arnold Kidney International Volume 70, Issue 4, Pages 765-770 (August 2006) DOI: 10.1038/sj.ki.5001554 Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 1 Identifies two of the main flow characteristics that we believe are the major determinates of DASS. Firstly, the arterial anastamosis is larger than the downstream artery feeding the hand. This favors graft flow. Secondly, the upstream and downstream arteries form an acute angle diverting flow preferentially into the graft. This patient had severe ischemic symptoms until the 4mm MILLER ligature was placed. Kidney International 2006 70, 765-770DOI: (10.1038/sj.ki.5001554) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 2 A 68-year-old female with right upper arm brachial artery to cephalic vein fistula presented with DASS. She was referred to her vascular surgeon who placed a clip proximally attempting to correct the steal syndrome. The patient then returned with persistent severe steal symptoms and underwent a MILLER procedure, which sized the flow restricting band to 4mm. The patient had an immediate resolution of symptoms. Kidney International 2006 70, 765-770DOI: (10.1038/sj.ki.5001554) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 3 This is a left upper arm brachial artery to cephalic vein fistula. A catheter is placed into the proximal (upstream) artery and 5cm3 of contrast are injected over 1s. Nearly 100% of arterial flow enters the fistula. No contrast is noted distal to the fistula anastomosis. This is typical of DASS. Kidney International 2006 70, 765-770DOI: (10.1038/sj.ki.5001554) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 4 Patient in Figure 1 post-MILLER procedure. A catheter is placed into the proximal (upstream) artery and 5cm3 of contrast are injected over 1s. A MILLER ligature is noted at the large arrow. Contrast can be seen distal to the access anastamosis indicating a return of perfusion to the hand. Kidney International 2006 70, 765-770DOI: (10.1038/sj.ki.5001554) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 5 Patient with right forearm fistula with isolated vein through a 1.5cm incision. Kidney International 2006 70, 765-770DOI: (10.1038/sj.ki.5001554) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 6 A nylon suture (2.0) passed around the patients right forearm fistula vein before tying the MILLER ligature. Kidney International 2006 70, 765-770DOI: (10.1038/sj.ki.5001554) Copyright © 2006 International Society of Nephrology Terms and Conditions

Kidney International 2006 70, 765-770DOI: (10.1038/sj.ki.5001554) Copyright © 2006 International Society of Nephrology Terms and Conditions