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

Abstract

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.

Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation

“…Several authors have advocated performance of the brachial bypass alone or the use of an alternative procedure such as proximalization of arterial inflow or the use of a more distal inflow source (RUDI). [14][15][16] Each of these alternate procedures has its disadvantages. Failure to perform the interval ligation may compromise procedural success.…”

Dialysis-associated steal syndrome (DASS)

“…It has also been reported that distal revascularization (DR) without interval ligation can be effective in relieving DASS (26, 27), especially if the distance between the AVA and the proximal anastomosis is >10 cm (2).…”

Comments on: The DRIL procedure for arteriovenous access ischemic steal: a controversial approach

“…DR without IL, as advocated in the editorial article, increases blood flow and pressure in the DBA via bypass, but it also increases retrograde flow into the access. In the first article cited (7), one patient had ischemic steal from a loop configuration (LC) access for which only DR was performed. Because of the LC, retrograde flow is rather minimal to begin with and the bypass flow is not able to travel backward over a long distance and reach the anastomosis area.…”