Prediction of graft patency and mortality after distal revascularization and interval ligation for hemodialysis access-related hand ischemia

Abstract

The treatment goals of access-related hand ischemia (ARHI) are to reverse symptoms and salvage the access. Many procedures have been described, but the optimal treatment strategy remains unresolved. In an effort to guide clinical decision making, this study was undertaken to document our outcomes for distal revascularization and interval ligation (DRIL) and to identify predictors of bypass patency and patient mortality. A retrospective review was performed of all patients who underwent DRIL at the University of Florida from 2002 to 2011. Diagnosis of ARHI was based primarily upon clinical symptoms with noninvasive studies used to corroborate in equivocal cases. Patient demographics, procedure-outcome variables, and reinterventions were recorded. Bypass patency and mortality were estimated using cumulative incidence and Kaplan-Meier methodology, respectively. Cumulative incidence and Cox regression analysis were performed to determine predictors of bypass patency and mortality, respectively. A total of 134 DRILs were performed in 126 patients (mean [standard deviation] age, 57 [12] years) following brachial artery-based access. The postoperative complication rate was 27% (19% wound), and 30-day mortality was 2%. The wrist-brachial index and digital brachial index increased 0.31 (0.25) and 0.25 (0.29), respectively. Symptoms resolved in 82% of patients, and 85% continued to use their access. Cumulative incidences (± standard error of the mean) of loss of primary and primary-assisted patency rates were 5%± 2% and 4%± 2% at 1 year and 22%± 5% and 18%± 5% at 5 years, respectively, with mean follow-up of 14.8 months. Univariate predictors of primary patency failure were DRIL complications (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.2-8.9; P= .02), configuration other than brachiobasilic/brachiocephalic autogenous access (OR, 3.4; 95% CI, 1.4-8.3; P= .009), and two or more prior access attempts (OR, 4.1; 95% CI, 1.6-10.4; P= .004). Brachiocephalic access configuration (OR, 0.2; 95% CI, 0.04-0.8; P=.02) and autogenous vein conduit (OR, 0.2; 95% CI, 0.06-0.58; P= .004) were predictors of improved bypass patency. All-cause mortality was 28% and 79% at 1 and 5 years, respectively. Multivariable predictors of mortality were age >40 (hazard ratio [HR], 8.3; 95% CI, 2.5-33.3; P= .0004), grade 3 ischemia (HR, 2.6; 95% CI, 1.5-4.6; P= .0008), complication from DRIL (HR, 2.4; 95% CI, 1.3-4.5; P= .004), and smoking history (HR, 2.2; 95% CI, 1.3-4; P=.007). Patients with no prior access attempts had lower predicted mortality (HR, 0.5; 95% CI, 0.3-0.9; P= .02). The DRIL procedure effectively improves distal perfusion and reverses the symptoms of ARHI while salvaging the access, but the long-term survival of these patients is poor. Given the poor survival, preoperative risk stratification is critical. Patients at high risk for DRIL failure and mortality may be best served with alternate remedial procedures.