Distal Revascularization and Interval Ligation “DRIL” Procedure in Steal Syndrome Management in Hemodialysed Patients

Abstract

Background: Steal syndrome complicates access in an increasing number of chronic renal failure (CRF) patients. Surgical procedures as (banding or fistula ligation) to manage this issue have proved to be entirely unsatisfactory because of loss of the recently created access through ligation or attempted salvage by increasing resistance within the fistula. Objective: To determine the results of DRIL technique in treating steal syndrome in CRF patients. Methods: A retrospective study (2015 to 2017) was conducted on 49 patients complaining of steal syndrome (out of 1200 CRF patients) with ages ranged from 35 to 71 years (mean=57 years) after obtaining written informed consent. Twenty nine patients were females (59.1%) and 20 (40.9%) were males. These subjects have undergone DRIL procedure in Vascular Surgery Departments, Qena and Assiut University Hospitals. Pre-procedural angiography was performed in most cases. Patient characters, risk factors, types of fistulae and indications for surgery were listed. The clinical outcomes of the procedure, Arteriovenous Access (AVA) and bypass graft patency were determined as well. Results: The AVA, which led to steal syndrome, was proximally located in the arm (brachiocephalic in 14, brachiobasilic in 14, and prosthetic brachio-axillary in the remaining 21 patients). Steal symptoms comprised hand ache, neurologic deficiency and gangrenous ulcerations. The procedure was technically effective in all subjects. Prompt and total pain release was accomplished in 43 (87.7%) of the 49 patients. One patient (2%) with gangrene later underwent transmetacarpal amputation. No patient required hand amputation. During follow-up (range 0.5 ± 17 months) hemodialysis was carried out continuously using the AVA in 40 subjects. AVA thrombosis had happened in 8 (16.3%) subjects only post DRIL. Significant difference was found between diabetes and occurrence of steal syndrome (p value<0.05) and between type of fistula (prosthetic AVF) and steal syndrome as well (p value<0.05). Six subjects died from other causes not related to the performed procedure. Conclusion: In certain subjects DRIL technique is a secure and efficient method to manage steal syndrome. AVA durability is not influenced by this procedure. Pre-operative angiography pre and post AVA manual compression is essential for adequate patients’ selection in which benefit will be gained mostly by the performed procedure.