https://doi.org/10.1177/1129729819894774 The Journal of Vascular Access 1–11 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1129729819894774 journals.sagepub.com/home/jva JVA e Journal of Vascular Access Introduction Hemodialysis access-induced distal ischemia (HAIDI) has been reported to have an incidence of 1%–8%. 1 However, this is based on referred cases requiring surgi- cal treatment. Its true frequency is dependent upon the symptom threshold used to qualify for the diagnosis. Systematic patient evaluation has shown that mild to moderate symptoms occur much more frequently. 2 The reported incidence relates to the upper extremity and is the topic of this review. Access-related distal ischemia can also involve the lower extremity with serious conse- quences. 3,4 An understanding of HAIDI and the appropri- ate role of the interventional nephrologist in its management is important when patients present with symptoms suggestive of HAIDI. Herein, the pathophysi- ology of the syndrome is discussed followed by recom- mendations for its diagnosis and management and the basis for the recommendations. These recommendations ASDIN white paper: Assessment and management of hemodialysis access- induced distal ischemia by interventional nephrologists Gerald A Beathard 1 , William C Jennings 2 , Haimanot Wasse 3 , Surendra Shenoy 4 , Dirk M Hentschel 5 , Kenneth Abreo 6 , Aris Urbanes 7 , George Nassar 8,9 , Bart Dolmatch 10 , Ingemar Davidson 11 and Arif Asif 12 Abstract Although not common, hemodialysis access-induced distal ischemia is a serious condition resulting in significant hemodialysis patient morbidity. Patients with signs and symptoms suggestive of hand ischemia frequently present to the general and interventional nephrologist for evaluation. In order to care for these cases, it is necessary to understand this syndrome and its management. Most cases can be managed conservatively without intervention. Some cases requiring intervention may be treated using techniques within the scope of practice of the interventional nephrologists while other cases require vascular surgery. In order for the interventional nephrologists to evaluate and manage these cases in a timely and appropriate manner, practice guidelines are presented. Keywords Dialysis access, AV fistula, prosthetic grafts, hand ischemia, steal syndrome, interventional nephrology Date received: 20 August 2019; accepted: 19 November 2019 1 University of Texas Medical Branch, Galveston, TX, USA 2 School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA 3 Rush University Medical Center, Chicago, IL, USA 4 Barnes-Jewish Hospital, Washington University, St. Louis, MO, USA 5 Renal Division, Brigham Health, Boston, MA, USA 6 School of Medicine, LSU Health Shreveport, Shreveport, LA, USA 7 Internal Medicine, Wayne State University, Detroit, MI, USA 8 Weill Cornell Medicine, New York, NY, USA 9 Houston Methodist Hospital, Houston, TX, USA 10 Palo Alto Medical Foundation, Palo Alto, CA, USA 11 University of Texas Southwestern Medical Center, Dallas, TX, USA 12 Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, USA Corresponding author: Gerald A Beathard, University of Texas Medical Branch, 5135 Holly Terrace Drive, Houston, Texas 77056, USA. Email: gbeathard@msn.com 894774JVA 0 0 10.1177/1129729819894774The Journal of Vascular AccessBeathard et al. editorial 2019 Editorial