Distal revascularization-interval ligation: an effective treatment for limb salvage and maintenance of dialysis access in ischemic steal syndrome

ABSTRACT

Dialysis access associated steal syndrome is an uncommon complication after creation of an arteriovenous fistula specially proximal one. Manifest steal syndrome has been managed with several procedures in the form of banding or ligation. Unfortunately, these techniques usually result in loss of a functional vascular access, inconsistent limb salvage or both. We report our experience with an alternative method of limb revascularization that eliminates steal while maintaining continuos dialysis access. A retrospective review was performed for reports of all patients who underwent distal revascularization-interval ligation [DRIL] procedure for access induced hand ischemia. The study was conducted between June 2000 and April 2004. Data regarding type of vascular access, timing of hand ischemia, access and bypass patency, limb salvage and patient survival were collected. We reported an incidence of 2.5% of hand ischemia following proximally situated autogenous access procedure. We performed 18 DRIL procedures in 18 patients [11 female and 7 male], mean age 59 years [21 to 82 years]. Hand ischernia was diagnosed within 30 days of the access procedure in 6 patients. Twelve patients had chronic ischemia, with tissue loss in 2, dry finger gangrene in 2, and dialysis induced ischemic pain in 8 patients. Primary access procedures were brachio-cephalic in 14 patients and brachio-basilic with superficialization in 4 patients. Follow up period was ranged from [1-36 months], mean 8 months. Immediate relief of ischemic manifestation was in all patients. Patency rate of bypass graft was 94%, with 89% patency rate for primary access procedure. Minor limited amputation was performed in 2 patients due to preoperative finger gangrene with complete stump healing. DRIL procedure is a durable and effective procedure in fulfilling the dual challenges. of access induced ischemic steal syndrome, including persistent relief of ischemic steal syndrome and continued access patency