Contemporary Outcomes of Distal Radial Artery Ligation for Access-related Hand Ischemia

Abstract

Access-related hand ischemia (ARHI) is a rare albeit morbid complication of hemodialysis access creation. Distal radial artery ligation (DRAL) has been described as a potential strategy to improve perfusion to the hand while maintaining the access. However, data for the safety and efficacy of this technique are limited to small case reports with limited follow-up. The objective of this study was to report longitudinal outcomes of distal radial artery ligation for ARHI in a contemporary cohort. We performed a retrospective cohort study (2015-2021) of all patients who underwent DRAL for ARHI or high flow at a tertiary care vascular center. Patients were identified using the Mass General Brigham clinical data registry and data collection was supplemented with chart adjudication. Outcomes captured included 30-day complications, and 1-year rates of improvement in ARHI-related symptoms. The cohort consisted of 31 patients. Mean age was 59.9 ± 14.5 years and 67.7% were male. Median follow-up was 335 days (interquartile range [IQR], 285-360 days). Wrist radial-cephalic (74.2%) and proximal radial-cephalic (9.7%) configurations were the most common. At baseline, ARHI severity was as follows: 38.7% stage 2 (pain during exercise or dialysis); 41.9% stage 3 (pain at rest); and 9.7% stage 4 (tissue loss). High flow was present in 35.5% of patients at baseline with median flow of 1670 mL/min (IQR, 1478-1954mL/min). After DRAL, median flow reduction in the high-flow group was 953 mL/min(IQR, 645-993mL/min) (Table); concurrent precision banding was performed in 29%. The 30-day complication rate after distal radial artery ligation was 3.2% (n = 1 access thrombosis). During longitudinal follow-up, 75% showed improvement in symptoms and 10.7% patients needed an additional procedure for ARHI. Carpal tunnel surgery was required for improvement in 7.1% of patients and was suspected as the culprit of symptoms in an additional 7.1% (Figure). Distal radial artery ligation for access related hand ischemia and or high flow is safe and can improve ischemic symptoms in most patients while salvaging access function. Carpal tunnel syndrome can explain access-related hand symptoms in approximately 15% of patients, and should be considered as a differential diagnosis in the assessment of this challenging patient population.TableIntraoperative details and postoperative outcomes after distal radial artery ligation (DRAL)CharacteristicTotal N (%) (n = 31)Concurrent procedure performed Banding9 (29.0) Side branch ligation7 (22.6) Angioplasty1 (3.2) Aneurysmorrhaphy2 (6.5)Follow-up, days333 (285-360)Flow reduction in high-flow group (mL/min) (n = 8)953 (645-993)30-Day complications Infection0 (0) Bleeding0 (0) Fistula thrombosis1 (3.2) Tissue loss healed if present (n = 3)2 (66.6)ARHI, Access-related hand ischemia.Data reported as counts (percentages) or median interquartile range. Open table in a new tab