Distal Revascularisation with Interval Ligation (DRIL): An Experience

Abstract

Grade 0 No steal.Grade 1 Mild (cool extremity with few symptoms but demonstrable by flow augmentation with access occlusion) -no treatment required. The clinical assessment of steal syndrome is often difficult as other factors like concomitant peripheral vascular disease and peripheral neuropathy can influence the clinical picture. A warm hand with a palpable ipsilateral radial pulse distal to the fistula suggests a problem other than steal. However, the converse is not true. An absent radial pulse in a fistula patient does not necessarily indicate steal syndrome. This is supported by a study 7 in which one-third of the 180 patients included had an absent radial pulse yet only 7 developed clinical symptoms of ischaemic steal.The diagnosis of ischaemic steal has been a topic of much debate, with several methods suggested. The four main methods include photo-plethysmography, pneumaticplethysmography, Doppler ultrasonography and digital pulse oximetry. These all monitor the waveform produced by blood flow within the digital arteries. A pronounced increase in waveform amplitude following manual external fistula compression is described.8 This external pressure effectively removes the fistula from the systemic circulation and returns blood-flow along its 'natural' pathway, thereby confirming a diagnosis of fistula-induced steal.In considering interventional surgery for symptomatic steal, there are two requirements -the preservation of uninterrupted vascular access and resolution of the distal ischaemia.3 Current techniques aim to satisfy these requirements, in the most simplistic, readily available and reliable manner, with the exception of fistula ligation which sacrifices the fistula in order to eliminate steal, but with construction of a new fistula in an alternative location, either on the ipsilateral or contralateral arm. The approach to intervention can be divided into two groups, one based on reduction of fistula flow by increasing its resistance, and the other by increasing the blood supply to the artery distal to the fistula.Surgical approaches can include banding of the fistula, clipping, insertion of a tapered graft or undertaking the DRIL procedure. Surgical techniqueThe DRIL procedure was first described in 1988 by Schanzer et al. 9 However, it has not been widely adopted because of concerns about its complexity and long-term efficacy.1 The DRIL procedure consists of two parts (Figs 1 and 2):1. Distal revascularisation is achieved with a bypass graft which has its origin from the graft artery, above the AVF, and ends with an end-to-side anastomosis, again to the graft artery but just distal to the AVF.2. Interval ligation is the simple cutting and tying of the graft artery distal to the AVF but proximal to the bypass graft anastomosis.The bypass graft provides a low-resistance pathway that runs in parallel to the artery, thus reducing the total system and more specifically, the peripheral resistance. ResultsIn our unit, five DRIL procedures were completed with a further procedure in another unit followi...

Distal revascularization and interval ligation (DRIL) procedure requires a long bypass for optimal inflow

“…The technique involves ligation of the brachial artery distal to the AVF inflow and revascularization of the distal arm with a bypass taken from a more proximal inflow source. 11 Good outcomes following DRIL have been reported by many authors; [12][13][14][15][16][17][18] however, technical factors associated with failure of the procedure have not been identified. Furthermore, details on operative technique, particularly the level of the bypass inflow, are often lacking.…”

Arteriovenous access ischemic steal (AVAIS) in haemodialysis: a consensus from the Charing Cross Vascular Access Masterclass 2016

“…Following flow reduction treatment (banding and branch tie off) the SaO2 improved in all patients to between 80% and 100% (39). In two small series improvement in Sa02 following treatment is described but not quantified (40, 41).…”

“…A recent systematic review of distal re-vascularisation interval ligation (DRIL) (64) included 15 studies with 513 patients (20–21–22, 35, 40, 43, 53, 68–69–70–71–72–73–74–75–76–77).…”

A Holistic Approach to Vascular Access in Hemodialysis

“…It can present hyperacutely with complete anaesthesiae of the hand, pain, loss of motor function or culminate in a more chronic form as severe ulceration and gangrene (Grade IV steal syndrome). Acutely, this represents a surgical emergency and necessitates immediate management to improve perfusion including revision surgery such as the distal revascularisation and interval ligation (Dril) procedure or reversal of the fistula to prevent permanent injury [34].…”