Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation

BackgroundArterial steal syndrome after angioaccess surgery can lead to potentially devastating complications. Past treatments either ensured loss of the newly created access through ligation or attempted salvage by increasing resistance within the fistula. None of these proved to be entirely satisfactory. In 1994, we began to employ distal revascularization with interval ligation (DRIL) as our primary method of relieving hand ischemia after dialysis access creation. Described here is our experience with this procedure.MethodsAfter institutional review board approval, the charts of patients undergoing the DRIL procedure for relief of hand ischemia after dialysis access surgery were reviewed. Patient demographics, risk factors, types of fistulas, and indications for operation were recorded. The clinical results of DRIL surgery, as well as fistula and bypass graft patency, were noted.ResultsBetween May 1994 and August 2011, 81 DRIL procedures were performed on 77 patients ranging from 37 to 94 (mean, 65) years of age. Forty-four were female and 33 were male, with diabetes present in 83.3%. DRIL procedures were performed for ischemic symptoms after 37 autogenous brachiocephalic, 30 prosthetic bridge, and 14 autogenous brachiobasilic fistulas. Thirty-eight DRIL procedures were performed for ischemic rest pain (46.9%), 21 for digital ulceration (25.9%), 16 for neurological deficits (19.7%), and six for digital gangrene (7.4%). Complete symptom resolution was seen in 31 patients with ischemic rest pain (81.6%), 19 patients with digital ulcerations (90.5%), nine patients with neurological deficits (56.3%), and five patients with digital gangrene (83.3%). Fistula and brachial-brachial bypass survival 60 months after the DRIL procedure was 56% and 96.9%, respectively. The overall complication rate was 17.2%, and no patients died within 30 days of operation.ConclusionsThe DRIL procedure is a very effective treatment for symptomatic steal syndrome and is associated with low morbidity and mortality. It is extremely effective in the treatment of ischemic hand pain and tissue loss, but less so for neurological sequelae. It can allow for prolonged fistula utilization