Surgical Treatment, with Using Distal Revascularization Interval-Ligation, for the Ischemia that Follows Creation of Hemodialysis Access

Song, Dan; Moon, Chul

Abstract

PURPOSE: The hand ischemia that's related to the construction of a vascular access is a serious and occasionally devastating complication. The traditional options for treating ischemic steal syndrome related to a functioning dialysis access graft or fistula include banding or ligation. Yet these procedures are directed toward increasing the resistance in the fistula, and they have yielded unreliable results. The technique of distal revascularization interval ligation provides satisfactory results in terms of healing of lesions, relief of symptoms and maintaining the vascular access. We report here on our experience with the DRIL procedure for relieving hand ischemia and maintaining the access patency in the setting of hemodialysis access-induced ischemia.
METHODS
We performed a retrospective review of all patients who underwent the DRIL procedure for treating access-induced ischemia. The physicians' office charts and hospital records were reviewed to determine the demographic data, the time to development of symptoms, the access and bypass patency, limb salvage and patient survival.
RESULTS
From January 2001 and August 2005, the DRIL technique was used to treat 13 patients (8 women and 5 men: mean age: 59.6 years, 9 diabetic patients) who had functioning extremity fistulae and they presented with critical ischemia and steal syndrome. 9 patients had chronic ischemia, and acute ischemia developed in 4 patients. The fistulae were located at the elbow in 13 patients (4 brachiocephalic AVFs, 9 upperarm bridge grafts). The conduit used for the DRIL arterial bypasses (13 brachiobrachial bypasses) was the great sahpenous vein graft in 12 patients and an artificial graft was used in 1 patient. 2 patients had thrombotic occlusion in their arterial bypass. Open thrombectomy was used to treat all the patients. Limb salvage and maintenance of a functional fistula were achieved in 100% of the patients.
CONCLUSION
The DRIL procedure is the effective, suitable treatment for relieving hand ischemia without sacrificing the fistula. We recommend the DRIL procedure to all access surgeons as the good choice for dealing with the complex problems of steal syndrome, which is induced by a functioning AV access.