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Abstract

I respectfully submit that the article by Zanow et al merits the designation “new.” They have reported the first large series with the proximilization of arterial inflow (PAI) procedure, encompassing 30 patients with documentation of mean flow, digital pressures, and clinical outcomes for multiple different access combinations over a mean follow-up of 26 months. The references provided in the letter to the editor include some innovative work with lower extremity access, banding, and a very nice theoretical construct expanding on a similar “electrical circuit” model initially described by David Sumner in 1975. Despite this, the primary reference to the PAI-type procedure in the letter (Gradman WS, Pozrikidis C. Ann Vasc Surg 2004;18:59-65) is a theoretical construct and the anecdotal report of a single clinical case with no follow-up. The references to other authors are for distal revascularization-interval ligation (DRIL) reports and anecdotal comments on those reports with no data provided. Thus, the report by Zanow et al is novel and provides enough clinical information to incorporate into clinical decision-making. Regarding other comments, I do not believe the PAI procedure is “hemodynamically identical to the DRIL procedure.” Yes, there are hemodynamic similarities, as pointed out in my commentary, but they are clinically quite different, as there is no arterial ligation, which is the point of the report. With regard to “distal revascularization without interval ligation,” I made no attempt to state that I invented the procedure. I only used it to point out similarities in the hemodynamic concept for an operation I have personally used. Finally, the hemodynamic explanation in my commentary is consistent with the “electrical circuit” model for steal. The letter states “… in the reconfigured circuit, flow to the hand originates at a point with higher pressure.” While a somewhat confusing way to describe it, flow to the hand could not “originate at a point with higher pressure” unless there was less pressure drop across the proximal anastomosis, and this requires a larger inflow artery better capable of handling the flow, as described in the commentary. Regarding “Proximalization of the arterial inflow: a new technique to treat access-related ischemia”Journal of Vascular SurgeryVol. 44Issue 5PreviewZanow et al1 have published an important series confirming the role of proximalization of the arterial inflow (PAI) for treatment of the steal syndrome. The operation they describe does not, however, merit the designation “new” (as placed on the Journal cover, the title, and in Dr Fillinger’s invited commentary)—only its acronym. The authors acknowledge that Dr Haimov and colleagues2 reported their serendipitous discovery of the procedure in 1996, but they only speculated on how it improves distal flow. Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 44Issue 5PreviewWe are well aware of the important contributions by Dr Gradman showing his experience in the treatment of ischemia after access construction. The use of the axillary or femoral artery for an arteriovenous (AV) access in a looped configuration is indeed not a new procedure. The reports cited in the letter are concerned with the primary construction of axillary or femoral looped access or with cases of conversion of prosthetic brachial-axillary access to a looped configuration, and we referred to them in our article. Full-Text PDF Open Archive