Midterm outcome after the distal revascularization and interval ligation (DRIL) procedure

Abstract

The distal revascularization and interval ligation (DRIL) procedure has evolved as the optimal treatment for access-related hand ischemia despite concerns about its durability. This study was designed to review our institutional experience and objectively define its mid-term outcome. A retrospective review of all patients undergoing the DRIL procedure was performed. The diagnosis of severe hand ischemia was made based primarily upon clinical presentation, but confirmed with noninvasive imaging in select cases. The DRIL conduit was selected based upon noninvasive imaging (vein conduit criteria: saphenous > arm; diameter >/=3 mm) and the proximal anastomosis was positioned >/=7 cm from the access anastomosis. The DRIL bypasses were followed in a graft surveillance protocol and remedial procedures performed as dictated by clinical or ultrasound scan findings. Sixty-four DRIL procedures were performed in 61 patients (age - 58 +/- 13 standard deviation [SD], female - 62%, diabetic - 72%). The index access procedures included: autogenous brachiocephalic - 46%, autogenous brachiobasilic - 31%, autogenous brachioaxillary translocated femoral vein - 20%, other -3%. The precipitating symptoms were pain (25%), paresthesia (34%), motor dysfunction (24%), and tissue loss (17%); a pre-emptive DRIL was performed in 5 patients. The timing of the DRIL relative to the index access was dictated by the symptoms: <24 hrs - 19%; 1 day </= DRIL </=7 days - 29%; 7 days </= DRIL </=30 days - 8%; >30 days - 44%. Perioperative mortality rate was 3% and the complication rate was 22% (wound - 14%). The DRIL procedure relieved the ischemic symptoms in 78% of the cases (residual symptoms: paresthesia - 13%; pain - 5%; tissue loss - 4%; motor - 2%). The DRIL also resulted in significant (P < .05) increases in both the wrist/brachial index (WBI) and digital/brachial index (DBI) with the mean increases of 0.34 +/- 0.26 and 0.41 +/- 0.21, respectively. The primary DRIL patency rates (+/- standard error of the mean [SEM]) were 77 +/- 8%, 74 +/- 9%, and 71 +/- 9% at 1 year, 3 years, and 5 years, respectively, while the corresponding secondary patency rates were 81 +/- 7%, 76 +/- 9%, and 76 +/- 9%, and the survival rates were 71 +/- 6%, 59 +/- 7%, and 33 +/- 9%. The index access procedure went on to mature sufficiently for cannulation in 68% of the cases when the DRIL was performed early (ie, <3 months from index access); all accesses functional at the time of the DRIL were used for dialysis throughout the perioperative period. The DRIL procedure safely and effectively relieves the symptoms of severe access-related hand ischemia while preserving the access. The midterm results suggest that the DRIL bypasses are durable, although long-term graft surveillance may be justified given the observed failures.