Revision Using Distal Inflow Research Articles

Efficacy of Revision Using Distal Inflow in Patients with Symptomatic Dialysis Access-Associated Steal Syndrome.

Objectives: In this study, we aim to assess the efficacy of revision using distal inflow (RUDI) in patients with symptomatic dialysis access-associated steal syndrome (DASS). Materials and Methods: All consecutive patients who were diagnosed with grade 3 or 4 DASS and have undergone RUDI in 4 years were included in this study. Results: In total, 35 patients were included in this study; participants had a mean age of 47.5±7.52 years and 54% (n=19) were males. As per our findings, significant improvement was noted in terms of paresthesia (81.2%, p-value: 0.012), coolness (79.4%, p-value: 0.006), pain (78.1%, p-value: 0.006), discoloration (76.4%, p-value: 0.044), paresis (71.4%, p-value: 0.016), and ulcer healing (50%, p-value: 0.044). Gangrene did not further progress in all patients (n=35). Reduction in fistula flow rate after RUDI was 57.5% (682±121 ml/min, p-value: 0.001). Digital systolic pressure was noted to improve by 71.4% (60±9.2 mmHg, p-value: 0.002) after RUDI. Peak systolic velocity increased in both ulnar (66.1±8.2 cm/s, p-value: 0.04) and radial (64.2±7.6 cm/s, p-value: 0.024) arteries of the wrist. Cumulative patency of RUDI graft was 100%, 91.4%, and 85.7% at 3, 6, and 12 months, respectively. Conclusion: RUDI has resulted in significant improvements in terms of DASS symptoms. Using a native vein as conduit, RUDI should be considered a procedure of choice for patients with high-flow DASS.

Balloon Angioplasty to Great Saphenous Vein Graft Interposed in RUDI

Vascular access-induced ischemia is an arteriovenous fistula (AVF) complication that can be treated surgically by interposing grafts to improve distal flow. However, over time, the interposed grafts may occasionally experience narrowing, which may require surgical or endovascular interventions for treatment. In this case report, we present a patient who underwent balloon angioplasty to address the narrowing observed in the great saphenous vein graft that had been interposed during a Revision Using Distal Inflow (RUDI) procedure.

Risk Factors and Management of Hemodialysis Associated Distal Ischemia

Hemodialysis-associated distal ischemia (HADI) is an uncommon, but significant complication after hemodialysis access creation that might require additional intervention. This study examines the risk factors for HADI and compares the outcomes of the different treatment modalities. The Vascular Quality Initiative hemodialysis access (2011-2019) registry was reviewed. Patients were classified based on the occurrence of HADI requiring intervention or not, and their respective characteristics were compared. Multivariable logistic regression was used to identify independent factors associated with HADI. Kaplan Meier curves of secondary patency after different modalities of surgical revision were compared. There were 35,236 vascular access creations and 970 (2.75%) were complicated by HADI requiring intervention. Treatment was performed with access ligation in 224 patients (23%) and catheter-based techniques in 394 (41%). Open surgical revision consisted of banding in 127 (13%), distal revascularization interval ligation (DRIL) in 196 (20%), proximalization of arterial inflow (PAI) in 15 (1.5%), and revision using distal inflow (RUDI) in 14 (1.4%). Median time to HADI was 49 days (IQR 17 -91 days). Multivariate regression demonstrated that white race, female sex, peripheral artery disease, coronary artery disease, diabetes, post-procedure antiplatelets, prosthetic grafts, upper arm access, and target vein diameter greater than 4 mm were significantly associated with increased risk for HADI. When compared to procedures without HADI, access patency was decreased when revision (excluding access ligation) was performed (secondary patency at 12 months, HADI revision versus none: 89.0% vs. 92.4%, P <0.01). However, after multivariate Cox adjustment, revision for HADI was not independently significantly associated with access failure. HADI complicates 2.75% of hemodialysis access cases and is more likely in white females with diabetes and arterial disease after upper arm prosthetic graft placement. The patency of dialysis access does not seem to be negatively impacted by the various methods of surgical revision for HADI.

Late Basilic Vein Superficialization Combined with Revision Using Distal Inflow (RUDI) Operation to Treat a Symptomatic High Flow Fistula

BackgroundVascular access (VA)-related high flows (HF) are common with brachial artery based fistulas. Flow-reduction procedures are indicated in symptomatic patients or asymptomatic ones with flows >2 L/min. However concomitant issues increase their complexity. We describe a case of a patient suffering congestive heart failure as a result of HF brachial-basilic fistula >3 L/min. A simultaneous late basilic vein transposition and revision using distal inflow (RUDI) was performed. MethodsA large diameter untransposed arterialized basilic vein was carefully and completely mobilized up to the proximal upper arm. After harvesting an autologous great saphenous vein (GSV) segment, a new inflow anastomosis was performed in the proximal ulnar artery. At the final stage, and after tunneling the mobilizing basilic vein in a subcutaneous semicircular configuration, an end-to-end anastomosis joining the two stumps (basilic vein outflow portion and GSV inflow arterial portion) was performed. A decision-making process in order to reach this complex option is discussed. Results Access flow and cardiac output were greatly attenuated following our approach. After a mean follow-up of 9 months no VA complications were observed, with flow still detected below 2 L/min. All cardiac symptoms and ultrasound investigations improved. ConclusionMultiple VA issues including HF pose a risk for abandonment and a challenge for the vascular surgeon. An effort toward increasing the “upper extremity life span” is advised.

Patency and Recurrence Rates of the Revision Using Distal Inflow Technique for High Flow Brachial Artery Based Arteriovenous Fistula

Introduction - High flow access (HFA; >2L/min or >1.5L/min with congestive complaints) is occasionally observed in the presence of a brachial artery based arteriovenous fistula (AVF).1 Several flow reducing techniques are available. Banding suffered from recurrence rates up to 50% within one year.2 Revision using distal inflow (RUDI) demonstrated a substantial flow reduction in the short term.3 Aim of this study was to report on the three-year patency and HFA recurrence rates of RUDI with interposition of the greater saphenous vein (GSV) in dialysis patients with a high flow access. Methods - Patients with a high flow elbow-based AVF scheduled for a RUDI procedure with use of the GSV between March 2011 and March 2017 in three facilities were followed for three years. Patency rates were defined as recommended by Sidawy.4 Recurrent high flow was defined as two consecutive high flow measurements (>2L/min) or signs of venous congestion or cardiac failure in presence of flows exceeding 1.5L/min. Patency and high flow recurrence were analysed using Kaplan-Meier analysis. Results - Twenty-one patients were studied (14 males, 54 ±3 years). RUDI was performed 44 ±12 months after the initial AVF construction. Peripheral arterial occlusive disease (5%) and diabetes mellitus (10%) were rarely observed while hypertension (52%) was more commonly present. Access flows decreased from 3220 ±204 mL/min preoperatively to 1150 ±88 mL/min postoperatively (P<0.001). Primary patency rates were 65% ±10, 54% ±12 and 54% ±12 after one, two and three years, respectively. Assisted patency rates were 79% ±9, 73% ±10 and 62% ±14, respectively. Secondary patency rates were 95% ±5, 95% ±5 and 76% ±14. In order to maintain access patency, twelve percutaneous transluminal angioplasties in eight and seven thrombectomies in four patients were conducted. Furthermore, two GSVs were replaced in a re-RUDI procedure (PTFE n=1; contralateral GSV n=1). HFA free survival was 74% ±10, 61% ±11 and 55% ±12 after one, two and three years. In the recurrence group, immediate postoperative access flow was higher when compared to the non-recurrence group (Flowrecurrence 1410 mL/min ±128, n=8 versus Flowno-recurrence 960mL/min ±87, n=11; P=0.012). The mean age in the recurrence group tended to be lower (Agerecurrence 46 ±4 years versus Ageno-recurrence 58 ±5years; P=0.082). Conclusion - A RUDI procedure with GSV interposition for HFA offers reasonably satisfactory patency rates after three years but requires maintenance. Recurrence free survival is higher when compared to rates described for banding. A relatively high immediate postoperative access flow is associated with recurrent high access flow.

Operative treatment of dialysis associated steal syndrome: basilic vein graft applied for revision using distal inflow (RUDI) procedure

Introduction: Artificial arterio-venous fistula-induced steal syndrome and subsequent distal ischemia are one of the most serious complications of arterial-venous fistula (AVF) surgery, ranging from 1 to 8% of cases. Traditionally, the complication is difficult to treat without losing the fistula. Treatment options include ligature of the fistula, fistula banding, distal revascularization with interval ligation (DRIL), proximalisation of the arterial inflow (PAI), and revision using distal inflow (RUDI). We would like to present a case of a 45-year-old woman who has developed dialysis associated steal syndrome with necrosis on the left arm 5 months after a cubital AVF was created. In order to maintain her arterio-venous fistula, RUDI procedure was performed to eliminate ischemia. We used basilic vein graft for distal revision of the astomosis. As a result of the procedure, ischemic complaints ceased, dialysis did not need to be interrupted, no further vascular access was necessary. Distalization of arterial inflow (RUDI) is an easy-to-implement, good-performing method for which the use of vena basilica graft is a very obvious solution.

Revision Using Distal Inflow for the Treatment of Dialysis Access Steal Syndrome: A Systematic Review.

The aim of this systematic review is to establish the efficacy of revision using distal inflow (RUDI) on the primary endpoints of complete dialysis access steal syndrome (DASS) resolution and arteriovenous fistula (AVF) longevity. An electronic search of literature from 1966 to 2017 in CINAHL, Medline, Embase and the Cochrane library according to PRISMA standards was conducted. Quality evaluations and recommendations for practice were examined. Data on power, age, gender, comorbidities, arterial inflow, conduit material, fistulae type, follow-up, failure incidence, ischaemia grade, modality of diagnosis, morbidity and mortality were subjected to pooled analysis of prevalence at a 95% confidence interval (CI). Eleven studies involving 130 individuals with a median age of 57 [interquartile ranges (IQR), 54–65] and equal gender distribution were conducted. Of the patients with diabetes mellitus (67.3%), the most common type of AVF with DASS was brachiocephalic AVF (73.7%). Overall, the prevalence of success was 82.0% (95%CI, 74.4%–89.6%) over 12 months (IQR, 1–40 months). Grade 3 ischaemia was the most common type of DASS (49.2%). Grade 4 had the worst outcomes compared with grades 2 and 3. The overall morbidity was 3% with no mortality. Overall, RUDI is an effective treatment for various grades of DASS and their longevity.

Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous Fistula

Upper arm arteriovenous fistulas (AVF) occasionally develop high flow. Revision using distal inflow (RUDI) effectively reduces flow of high flow accesses (HFA) in the short-term and is also popularised for treatment of haemodialysis access induced distal ischaemia (HAIDI). The long-term efficacy is unknown. The study's aim was to report on 3 year RUDI patency and recurrence rates for HFA with and without HAIDI. This was a retrospective cohort study of patients with a HFA with or without HAIDI undergoing RUDI using greater saphenous vein (GSV) interposition between March 2011 and October 2017at three facilities. AVFs were termed HFA if flow volumes exceeded 2L/min on two consecutive measurements using dilution techniques. HAIDI was diagnosed as recommended. Following RUDI, follow up was not different from standard care in AVF patients. Data on post-operative flows and re-interventions were extracted from electronic patient files. Loss to follow up was avoided. Rates of patency and HFA recurrence were analysed. During the observation period, 21 patients were studied (7 females, 54 years±3). Fourteen had uncomplicated HFA whereas seven had additional HAIDI. Immediately post-operatively, flows decreased threefold (3120mL/min±171 vs. 1170mL/min±87, p<.001). Overall 3 year primary patency was 48%±12 (HFA, 55%±15 vs. HAIDI/HFA, 29%±17, p=.042). Secondary patency was identical in both groups (overall, 84%±9). Interventions were percutaneous transluminal angioplasty (n=12, 9 patients), thrombectomy (n=7, 3 patients), and revision with new interposition grafts (n=3). After 3 years, 51%±12 were free of high flow (HFA, 32%±13 vs. HAIDI/HFA, 100%, p=.018). High immediate post-operative access flow predicted recurrence (OR 1.004 [1.000-1.007], p=.044). Patients with recurrence were 12 years younger than those without (p=.055). RUDI with GSV interposition for HFA offers acceptable patency rates after 3 years although re-interventions are often required. High immediate post-operative flows and young age are associated with recurrent high flow.

Management of Vascular Access Steal Syndrome after High Flow Arterio-venous Fistula with Revision Using Distal Inflow (RUDI) Technique

Management of Vascular Access Steal Syndrome after High Flow Arterio-venous Fistula with Revision Using Distal Inflow (RUDI) Technique

Access Flow Reduction for Cardiac Failure

High-flow in hemodialysis arteriovenous angioaccesses is frequent. It may result in high-output cardiac failure, which should be prevented by fistula flow reduction. The most frequently reported flow reduction procedure is banding but immediate and long-term results are questionable. Alternative techniques are related here with personal results. Juxta-anastomosis "Proximal Radial Artery Ligation" (PRAL) is a very simple and effective reduction technique for side-to-end radio-cephalic fistulas (82 patients; reduction rate [RR]: 54% ± 19%). For brachial artery-based fistulas flow reduction two variants of Revision Using Distal Inflow (RUDI) procedures are used: 1) RUDI-1 using a polytetrafluoroethylene (PTFE) graft or a greater saphenous vein, which we first described in 1989 as "Distal Report of the Arterial Inflow" (35 patients; RR: 53% ± 18%), 2) RUDI-2 procedure, "Transposition of the Radial Artery", which we described in 2009 (47 patients; RR: 66% ± 14%).

A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia

Access-related hand ischemia (ARHI) is a potentially limb-threatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival. A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe Society for Vascular Surgery grade 3 ARHI were included for analysis. A total of 2035 autogenous accesses were created during the study period, and 58 (3%) developed grade 3 ARHI. Of this cohort, RUDI was performed in 20 and DRIL in 21. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5years, and 54% of patients were female. Most patients had diabetes (86%) and symptomatic peripheral arterial disease (63%). The mean preoperative digital-brachial index was 0.25± 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Primary patency between the RUDI and DRIL cohorts at 12months (58%± 11% vs 55%± 12%) and 36months (51%± 12% vs 41%± 12%) were similar (P= .841). Cumulative secondary patency at 12months (84%± 8% vs 94%± 6%) and 36months (78%± 9% vs 86%± 9%) showed no significant difference (P= .398). Resolution of ischemic symptoms, including resolution or improvement in pain or healing ofischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P= .131). Survival for patients who underwent RUDI or DRIL procedures at 1 and 3years was 85% vs 86% (P= .948) and 55% vs 49% (P= .278). In this preliminary study, the RUDI demonstrated similar patency, symptom resolution, and survival compared with the DRIL for patients with severe ARHI. All-cause mortality after any procedure for severe steal syndrome is high, and the particular intervention for management of steal must account for anatomic-, patient-, and disease-related considerations.

Revision using distal inflow is a safe and effective treatment for ischemic steal syndrome and pathologic high flow after access creation

Ischemic steal syndrome (ISS) and pathologic high flow (HF) are a complications after hemodialysis access creation. Their management is complex and varied with most requiring surgical revision for correction of symptoms. Revision using distal inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience with RUDI for the treatment of ISS and pathologic HF. We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April, 2010 to March, 2014. Data collection included demographic characteristics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. We performed 29 RUDI procedures in 28 patients (16 women, 12 men). Indications for surgery were pathologic HF in 13 and ISS in 19. Ten percent had previous banding for ISS or HF. Sixty-nine percent of patients had a history of diabetes. Fifty-two percent had a history of atherosclerotic disease. Mean time to intervention from creation was 40 months (range, 6-88 months). Accesses included 1 upper arm graft and 27 brachial artery-based fistulas. Outflow included 25 cephalic veins and 3 basilic veins. Distalization targets were 19 radial arteries and 10 ulnar arteries. Mean flow reduction was 1191 mL/min. Primary assisted patency at 1 year was 74%. Secondary patency at 1 year was 87%. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 69% and partial in 31%. RUDI is an effective and durable treatment of ISS and HF comparable with reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and banding. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.

Síndrome isquémico de la mano secundario a acceso vascular para hemodiálisis. Estrategias terapéuticas

Access-induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. The construction of an arteriovenous access results in a predictable decrease in the perfusion pressure distal to the anastomosis, which can result in ischemia if the compensatory mechanisms are inadequate. Because many of the signs and symptoms are nonspecific, the diagnosis can be aided in equivocal cases with non-invasive vascular laboratory studies. A digital/brachial index < 0.45 is suggestive of severe ischemic syndrome, and is usually associated with pain at rest and/or trophic lesions on the fingers. The aims of the treatments are to reverse the hand ischemia and to preserve the access. There are a variety of treatments, including correction of the inflow lesion, access ligation, limiting the flow through the access (banding), distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI), or proximalization of arterial inflow (PAI). The optimal choice should be based on hemodynamic mechanisms and severity of symptoms, in conjunction with the access type and patient comorbidities. A review of the underlying pathophysiology and treatment options will be presented. To date, the DRIL procedure has been the most consistently successful strategy. However, the particular circumstances of each case demand an individualization of treatment.

Management and outcomes of dialysis access-associated steal syndrome

Dialysis access-associated steal syndrome (DASS) complicates arteriovenous access surgery. We describe a 10-year experience with the surgical management of DASS. DASS operations were retrospectively reviewed from July 2003 to July 2013 from a single academic institution. Demographics, symptoms, surgical details, and outcomes were collected. A total of 201 patients had 218 episodes of DASS. Mean age was 65 years, and 62% were women. DASS was caused by 175 arteriovenous fistulas (80%), 41 upper extremity prosthetic grafts (19%), and two thigh grafts (1%); 87% were brachial artery based. A portion (22%) were referred for DASS from outside practices. All patients had grade 2 (48%) or grade 3 (52%) DASS; 92% (185) were available for follow-up, with a median time to first follow-up of 23 days. Surgical procedures included ligation (73), distal revascularization with interval ligation (DRIL) (59), revision using distal inflow (RUDI) (21), banding (38), proximalization of arterial inflow (12), and distal radial artery ligation (13). There were no differences in preoperative comorbidities between treatment groups. The 30-day complications included continued steal, thrombosis, bleeding, infection, and mortality. Ligation and DRIL were performed most often for grade 3 steal. Ligation and banding were performed most acutely (median time to intervention after access creation of 39 and 24 days vs DRIL and RUDI at 97 and 100 days). Fistula preservation was 0% for ligation, 100% for DRIL, 95% for RUDI, and 89% for banding (P < .01). Improvement of symptoms ranged from 75% (banding) to 98% (DRIL) (P = .005). Women were less likely to have DRIL but more likely to have ligation (P = .001). Complications were highest in the banding (49%) and RUDI (37%) groups. Average mortality was 3.5%, with no significant differences among groups. During the study period, 3287 access procedures were performed, and access volume steadily increased (2003-2008, 1312 access creations; 2008-2013, 1975). Percentage of fistulas (79% vs 86%), incidence of steal (4% vs 6%), and percentage of DRILs (25% vs 28%) were consistent across the two study periods. DRIL and ligation were performed in patients with the most severe symptoms. Compared with ligation, DRIL has equal symptom resolution, no increase in complications, and fistula preservation. Compared with banding, DRIL resulted in superior fistula preservation and fewer complications. DRIL should be considered the preferred procedure for management of DASS in patients with a functioning autologous fistula who can tolerate a major operation.

Revision Using Distal Inflow: A Safe and Effective Treatment for Ischemic Steal Syndrome After Access Creation

Ischemic steal syndrome (ISS) is a dreaded complication after hemodialysis access creation. Its management is complex and varied, with most requiring surgical revision for correction of symptoms. Revision using distal inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience with RUDI for the treatment of ISS and pathologic high flow (HF). We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April 2010 to March 2014. Data collection included demographics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. We performed 32 RUDI procedures in 31 patients (18 women, 13 men). Indications for surgery were pathologic HF in 15 and ISS in 21. Sixteen percent had prior plication for ISS or HF. Seventy-one percent of patients had a history of diabetes, and 52% had a history of atherosclerotic disease. Time to intervention from creation was 40 months (range, 6-88 months). Accesses included one upper arm graft and 30 brachial artery-based fistulas. Outflow included 26 cephalic veins and four basilic veins. Distalization targets were 20 radial arteries, nine ulnar arteries, and three distal brachial arteries. Mean flow reduction was 994 mL/min. Primary assisted patency at 1 year was 73%, and secondary patency was 88%. The RUDI in one patient was revised from a distal brachial to radial inflow. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 81% and partial in 19%. RUDI is an effective and lasting treatment of ISS and HF and comparable to reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and plication. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.

Evaluation of the role of distal revascularization with interval ligation (DRIL) and revision using distal inflow (RUDI) in treatment of dialysis associated steal syndrome

Objective: Dialysis-associated steal syndrome (DASS) is a complication that may occur in >4% of patients with arteriovenous fistula. The best treatment method for this condition is up till now controversial. Aim of the work: The purpose of this study was to evaluate two common procedures to treat this condition; Distal Revascularization with Interval Ligation (DRIL) or Revision Using Distal Inflow (RUDI) aiming at preservation of both the function of the fistula and the limb. Patients and methods: Fourteen patients having native brachiocephalic or brachiobasilic hemodialysis AV fistula complicated by dialysis associated steal syndrome (DASS), were randomly divided according to treatment method into DRIL and RUDI groups with 7 patients in each group. Patients with proximal or distal arterial disease and those with low-flow steal were excluded Short term access patency and limb salvage were set as primary endpoints. In all patients great saphenous vein was harvested from the thigh. Early post-procedural follow up and mid-term follow up were after one and three months. Results: From November 2011 to March 2013, 14 patients presented with (DASS). In DRIL group (7 patients), the mean age was 49.2 years, 4 females and 4 diabetics while in RUDI group (7 patients), the mean age was 52.3 years, 5 females and 7 diabetics. All fistulas were brachiocephalic and only one was brachiobasilic AVF in DRIL group. All patients in both groups presented with pain, pallor, coldness and cyanosis of the hand Stage III DASS {rest pain) was present in 2 cases of each group, whereas Stage IV small superficial ulcers were present in 3 vs 4 and digital gangrene in 2 vs. 1 in DRIL vs. RUDI respectively In group 1 (DRIL) technique; 5 patients (71.4%) had marked improvement of pain, cyanosis, capillary refill and coldness. Pallor improved in all cases. Distal pulses returned in 4 patients, remained weak in one patient and failed to return in 2 (28.6%). Closure of the access was necessary in 2 patients due to infection in one and due to risk of limb loss in the other; access patency was (71.4%) and limb salvage was (100%). In RUDI cases, pain, hand coldness, pallor and cyanosis greatly improved in all cases post-operatively. Distal pulses and capillary refill returned and became comparable to the healthy side in 6 patients (85 7%). Limb salvage and access patency were achieved in all cases (100%). Conclusion: RUDI procedure incorporates most of the advantages of other access and hand-preserving procedures. In contrast to DRIL procedure, it is the fistula that is placed at risk by ligation and revascularization, not the native arterial supply to the ischemic hand RUDI may become the procedure of choice for patients with dialysis-associated steal syndrome after a brachial artery-based arteriovenous fistula.

Invited commentary

This study from the University of Pittsburgh addresses an important clinical problem after hemodialysis access creation: the ischemic steal syndrome (ISS). It is one of the largest series in the literature.1Gupta N. Yuo T.H. Konig G. Dillavou E. Leers S.A. Chaer R.A. et al.Treatment strategies of arterial steal after arteriovenous access.J Vasc Surg. 2011; 54 (in press)Google Scholar The pathophysiology of ISS is worth reviewing. The magnitude of blood flow through an arteriovenous fistula is a function of the diameter of both the fistula and the donor artery. Fistulas are classified by the fistula diameter relative to that of the donor artery. Small fistulas are defined as having a diameter <75% of the diameter of the inflow artery. In small fistulas, the primary determinant of the magnitude of fistula flow is fistula resistance, which varies with the fourth power of the diameter. The natural history of small fistulas is thrombosis. Large fistulas have a diameter >75% that of the donor artery, and the magnitude of blood flow tends to be independent of fistula resistance and diameter. In large fistulas, flow is determined primarily by the relative resistances of the peripheral vascular bed, the donor artery, and the collateral circulation. Most surgically created fistulas are of the large variety in order to provide sufficient blood flow (approximately 600 ml/minute) for dialysis.2Wixon C.L. Hughes J.D. Mills J.L. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access.J Am Coll Surg. 2000; 191: 301-310Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 3Wixon C.L. Mills J.L. Berman S.S. Distal revascularization-interval ligation for maintenance of dialysis access and restoration of distal perfusion in ischemic steal syndrome.Sem Vasc Surg. 2000; 13: 77-82PubMed Google Scholar Nearly all surgically created fistulas create physiological steal; ISS results when distal arterial perfusion is inadequate to meet tissue metabolic requirements.2Wixon C.L. Hughes J.D. Mills J.L. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access.J Am Coll Surg. 2000; 191: 301-310Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar Thus, it is no surprise that banding, which increases fistula resistance, is unlikely to achieve the dual goals of ISS treatment (ie, preservation of the access and relief of the ischemia). In this series, banding had poor outcomes. Nineteen percent of fistulas thrombosed after banding, and 48% of patients had persistent ischemia; 73% of reinterventions were performed in patients who underwent banding. Distal revascularization and interval ligation (DRIL) had a statistically better success rate than banding (P ≤ .05) and was effective in resolution of ISS in 90% of patients. DRIL remains the procedure of choice for treatment of ISS.4Knox R.C. Berman S.S. Hughes J.D. Gentile A.T. Mills J.L. Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access.J Vasc Surg. 2002; 36: 250-256Abstract Full Text PDF PubMed Scopus (153) Google Scholar I would urge future investigations of ISS to include hemodynamic data (digital arterial pressure measurements with and without fistula compression), which in my view, are essential to confirm the diagnosis and quantify severity.2Wixon C.L. Hughes J.D. Mills J.L. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access.J Am Coll Surg. 2000; 191: 301-310Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar While hemodynamic data were not routinely collected in this series, it is interesting to compare pre- and postoperative hemodynamics for those in whom they were available. Following the DRIL procedure, digital pressures increased from 43 to 75 mm Hg; after banding, the corresponding increase was only from 33 to 44 mm Hg. This difference was statistically significant and likely accounts for the failure of a substantial number of banded patients to improve. The authors report some experience with revision using distal inflow (RUDI) and proximalization of arterial inflow (PAI). While the reported results were excellent, patient numbers were low. These procedures likely work in a manner analogous to the DRIL procedure, by altering relative resistances (either by adding length or reducing donor artery diameter) rather than by increasing fistula outflow resistance. Such procedures, based on the physiology of ISS, are most likely to succeed. This is a well-written study of ISS. Hopefully, it will lay banding to rest. Future investigations, especially with the newer RUDI and PAI procedures, should include hemodynamic data and sufficient follow-up to allow comparison with the well-established DRIL procedure. Treatment strategies of arterial steal after arteriovenous accessJournal of Vascular SurgeryVol. 54Issue 1PreviewIschemic steal syndrome (ISS) associated with arteriovenous (AV) access is rare but can result in severe complications. Multiple techniques have been described to treat ISS with varying degrees of success. This study compares the management and success associated with these techniques. Full-Text PDF Open Archive

Revision Using Distal Inflow for Treatment of Heart Failure Secondary to Arteriovenous Fistula for Hemodialysis

In patients on hemodialysis, cardiovascular disease can be precipitated or worsened by the presence of a high flow arteriovenous fistula. Fistula closure and banding are the traditional treatment methods of dialysis associated high output cardiac failure. We present a case of fistula-related high output cardiac failure treated by revision using distal inflow (RUDI).

Modified Distal Revascularization with Interval Ligation Procedure for Steal Syndrome after Arteriovenous Fistula Creation for Hemodialysis Access

Patients diagnosed with steal syndrome after hemodialysis access surgery have a few options for symptom relief while maintaining vascular access. These include fistula lengthening, banding, distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI) or proximalization of the arterial inflow (PAI). Two cases are described in which a modified DRIL procedure without interval ligation was used to relieve steal syndrome, leaving the arterial supply of an ischemic hand not entirely dependent upon a bypass. Furthermore, a review of the literature is presented in order to elucidate this relatively new treatment option as a viable means to improve hand perfusion while maintaining a functional fistula.

Revision Using Distal Inflow: A Novel Approach to Dialysis-associated Steal Syndrome

Current access-preserving treatment options for dialysis-associated steal syndrome (DASS) include fistula lengthening or banding and distal revascularization interval ligation (DRIL). We describe a novel technique for the treatment of DASS that we have termed revision using distal inflow (RUDI). Briefly, the technique involves ligation of the fistula at its origin followed by reestablishment of the fistula via bypass from a more distal arterial source to the venous limb. Four patients with brachial artery-based arteriovenous fistula and DASS underwent RUDI as described above using either the proximal radial or ulnar artery as inflow and vein as conduit. Patients were diagnosed with DASS based on the clinical findings of pain, pallor, loss of radial pulse, and sensorimotor dysfunction after creation of an AVF. Noninvasive vascular studies confirmed diminished finger pressures that improved with compression of the fistula. All patients experienced rapid resolution of their symptoms, although one patient complained of mild residual parasthesias. Follow-up ranging from 4 to 14 months has revealed patent functional fistulas. These initial results demonstrate that RUDI can be an effective treatment of DASS. By design, RUDI incorporates many of the advantages of established access-preserving procedures. That is, by using a smaller distal artery as inflow, RUDI lengthens the fistula, decreases the radius, and preserves antegrade flow in the brachial artery. In contrast to DRIL, it is the fistula, not the native arterial supply, that is placed at risk by ligation and revascularization. Consequently, we believe that RUDI may become the procedure of choice for DASS after brachial artery-based fistulas.