Distal revascularization-interyal ligation [DRIL] versus banding for simulataneous correction of steal, and preservation of A-V hemodialysis access

ABSTRACT

Ischemic steal syndrome secondary to a hemodialysis arteriovenous access is a potentially serious complication. Two types of the syndrome are recognized; the immediate, and delayed type. This condition occurs due to marked decrease or reversal of flow in the arterial segment distal to the A-V fistula, induced by the low resistance of the fistula outflow. Of the work To compare the efficacy of two methods used in managing A-V dialysis access steal; DRIL, versus banding. Twenty six patients presenting with manifestations of steal following creation of a function A V shunt access. Fourteen patients underwent DRIL, and twelve patients underwent banding of the first 3-4 cm of the access beginning, adjacent to the A-V shunt Pre and post operative color Duplex for measuring the flow rates in proximal and distal arterial segment, and the flow rates in the access. Intraoperative pressure measurement were recorded before and after correction in the proximal and distal arterial segment using an invasive line. Acute steal cases were 26.9% compared to 73.1% delayed presentation. The sudden loss of part of the arterial flow into the access, in the presence of inefficient colla might be responsible for that. The distal arterial pressure improved significantly postoperatively in both groups. The major difference between the 2 groups was in the patency rate measured at 6 months postoperatively. It was 66.7% for banding, compared to 92.9% for DRIL although the results did not reach stastical significance. Thrombosis in a case occurred on third postoperative day, the others thrombosed between 2-6 months post correction. Diabetes effect on steal was well demonstrated in this aeries [88.5%] as well as female predominance [69.2%]. Banding had good results when the venous limb was dilated with associated compensatory proximal arterial hypertrophy which allowed narrowing of the outflow venous tract to 6-7 mm, with good palpable distal pulse, and good thrill at the fistula site. However, if infection is excluded, the DRJL results might have approached 100%, still, it showed higher patency trend