SUMMARY

This thesis aims to examine three key questions:

1. Can digital finger pressure measurements and the derivative digital brachial pressure index help to identify patients at risk of arteriovenous access ischaemic steal?

2. Is it possible to reduce reported rates of steal and steal phenomena in autogenous fistulae located at the antecubital fossa by modifying the arterial inflow used?

3. Should elderly patients initiating haemodialysis be consigned to a more proximal antecubital fossa (brachial) fistula, or is a more distal wrist (radiocephalic) fistula an acceptable alternative?

To address these questions, the vasculature of approximately 500 patients was analysed. The work presented in this thesis examines the use of digital finger pressures as a noninvasive diagnostic modality and underscores the importance of the digital brachial pressure index in the determination of steal phenomena and arteriovenous access ischaemic steal (AVAIS). We identified the incidence of steal phenomena in our cohort, which was of a greater scale than anticipated from the existing published literature. In Chapter 3, I present the findings for a randomised controlled trial comparing the incidence of steal syndrome and steal phenomena for 2 different autogenous fistulae sited at the antecubital fossa. Our results demonstrate that patients undergoing haemodialysis via antecubital fossa fistula experience a greater incidence of steal phenomena as compared to distal fistulae, and that by utilising the proximal radial or ulnar artery as arterial inflow, lower rates of steal phenomena are evident. Finally, Chapter 4 highlights the importance of establishing timely autologous vascular access in an elderly incident population. It emphasises that this group should not be disadvantaged by the creation of a more proximal access which might hasten exhaustion of venous capital.