An 18-Year Experience Utilizing Distal Revascularization With Interval Ligation (DRIL) as the Primary Treatment for Hand Ischemia Following Dialysis Access Creation

Abstract

Arterial steal syndrome after angioaccess surgery can lead to potentially devastating complications. Past treatments ensured loss of the newly created access by performing ligation or attempted salvage by increasing resistance within the fistula. None of these proved to be entirely satisfactory. In 1994, we began to use distal revascularization with interval ligation (DRIL) as our primary method of relieving hand ischemia after dialysis access creation. We describe our experience with this procedure. After Investigational Review Board approval, the records of all patients undergoing the DRIL procedure for relief of hand ischemia after dialysis access surgery were reviewed. Patient demographics, risk factors, type of fistula, and indications for operation were recorded. The clinical results of DRIL surgery, duration of fistula use for dialysis, and bypass graft patency were noted. Kaplan-Meier survival curves were created, and differences between groups were tested by the log-rank method. Fistula survival was defined as the duration of use before abandonment as the primary method of achieving dialysis access, and bypass graft survival was determined by clinical examination or duplex scan. Between May 1994 and August 2011, 81 DRIL procedures were performed on 77 patients (32 men, 45 women) with a mean age of 64 years (range, 37-91 years). Diabetes was present in 77.6%. DRIL procedures were performed for ischemic symptoms after 51 autogenous fistulas (37 brachiocephalic and 14 brachiobasilic), and 30 were created after prosthetic bridge fistulas. Thirty-eight DRILS were performed for patients with ischemic rest pain, 20 after the development of digital ulcers, 16 to help resolve neurologic symptoms, and seven to heal digital gangrene. After performance of the DRIL procedure, complete resolution of symptoms was noted in 90% of patients treated for digital ulceration, 81.6% of patients treated for ischemic rest pain, 56.3% of patients treated for neurologic deficits, and 42.9% of patients treated for digital gangrene. Overall fistula survival after the DRIL procedure was 70.1%, 57.8%, and 44.5% at 12, 24, and 36 months, respectively. Autogenous fistulas had a significantly longer survival after DRIL than prosthetic bridge fistulas (P = .009). The 5-year patency of the brachial-brachial bypass graft was 93.7%. No patients died ≤30 days of operation. The DRIL procedure is a very effective treatment of hand ischemia after dialysis access creation and can be performed with a low mortality. It is extremely successful in treating ischemic rest pain and digital ulceration, but less so when used to treat patients with digital gangrene and neurologic deficits. Autogenous fistula survival after the creation of the DRIL is excellent and considerably longer than that of prosthetic bridge fistulas.