Outcome after distal revascularization and interval ligation [DRIL] for the tratment of dialysis-associated steal synrome

ABSTRACT

The purpose of this study was to determine the efficacy and durability of the distal revascularization and interval ligation [DRIL] procedure in relieving hand ischemia and in maintianing access patency in the setting of hemodialysis access-induced ischemia. The traditional operative treatment for ischemic steal intervention syndrome related to a functioning dialysis access arterio-venous fistula [A/V fistula] usually result in inconsistent limb salvage, loss of access function or both. This study describes the "DRIL" technique for correction of ischemic steal syndrome occurring as a complication of A/V fistulas. The study was conducted on 20 patients with a functioning upper extremity A/V fistulas associated with ischemic steal syndrome and treated by "DRIL" procedure at El Hussein University Hospital, Vascular Surgical Unit. The indications for surgery were ischemic hand pain in 9 patients [45%], tissue loss in 7 patients [35%], loss of neurologic function in 2 patients [10%] and pain during hemodialysis in 2 patients [10%]. The surgical technique used consisted of ligation of the brachial artery distal to the inflow anastomosis to the fistula and bypass graft from the brachial artery 5cm above the fistula by end to side anastomosis to a point just distal to the A/V anastomosis. The bypass material used in these patients was synthetic polytetrafluroethylene grafts [PTFE grafts] 6 mm in diameter. Of total 20 patients with ischemic steal syndrome affecting the upper extremities occurred after A/V fistulas treated by "DRIL" procedure, their ischemic symptoms improved immediately after surgery in 18 patients [90%]. The primary patency of the brachial artery bypass was 90% and the patency of A/V fistulas was 85% at 1 year. The "DRIL" technique is effective in alleviating symptoms of ischemic steal syndrome and preserving the hemodialysis access. It is considered as the procedure of choice for correction of ischemic steal syndrome induced by A/V fistulas