A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia

Abstract

Access-related hand ischemia (ARHI) is a potentially limb-threatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival. A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe Society for Vascular Surgery grade 3 ARHI were included for analysis. A total of 2035 autogenous accesses were created during the study period, and 58 (3%) developed grade 3 ARHI. Of this cohort, RUDI was performed in 20 and DRIL in 21. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5years, and 54% of patients were female. Most patients had diabetes (86%) and symptomatic peripheral arterial disease (63%). The mean preoperative digital-brachial index was 0.25± 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Primary patency between the RUDI and DRIL cohorts at 12months (58%± 11% vs 55%± 12%) and 36months (51%± 12% vs 41%± 12%) were similar (P= .841). Cumulative secondary patency at 12months (84%± 8% vs 94%± 6%) and 36months (78%± 9% vs 86%± 9%) showed no significant difference (P= .398). Resolution of ischemic symptoms, including resolution or improvement in pain or healing ofischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P= .131). Survival for patients who underwent RUDI or DRIL procedures at 1 and 3years was 85% vs 86% (P= .948) and 55% vs 49% (P= .278). In this preliminary study, the RUDI demonstrated similar patency, symptom resolution, and survival compared with the DRIL for patients with severe ARHI. All-cause mortality after any procedure for severe steal syndrome is high, and the particular intervention for management of steal must account for anatomic-, patient-, and disease-related considerations.