Prediction of graft patency and mortality after distal revascularization and interval ligation for hemodialysis access-related hand ischemia

Abstract

Objective The treatment goals for access related hand ischemia (ARHI) are to reverse symptoms and salvage the access. Many procedures have been described, but the optimal treatment strategy remains unresolved. In an effort to guide clinical decision making, this study was undertaken to document our outcomes for distal revascularization and interval ligation (DRIL) and identify predictors of bypass patency and patient mortality. Methods A retrospective review was performed of all patients who underwent DRIL at the University of Florida from 2002–2011. Diagnosis of ARHI was based primarily upon clinical symptoms with non-invasive studies used to corroborate in equivocal cases. Patient demographics, procedure-outcome variables and re-interventions were recorded. Bypass patency and mortality were estimated using cumulative incidence and Kaplan-Meier methodology, respectively. Cumulative incidence and Cox regression analysis were performed to determine predictors of bypass patency and mortality, respectively. Results 134 DRILs were performed in 126 patients (age 57±12yrs (mean±SD)) following brachial artery-based access. The post-operative complication rate was 27% (19%-wound), and 30-day mortality was 2%. The wrist/brachial (WBI) and digital/brachial (DBI) indices increased 0.31±0.25 and 0.25±0.29, respectively. Symptoms resolved in 82% of patients, and 85% continued to use their access. Cumulative incidences of loss of primary and primary-assisted patency rates were 5±2%, 4±2% and 22±5%, 18±5% at 1 and 5 years, respectively with a mean follow-up of 14.8 months. Univariate predictors of primary patency failure were DRIL complications (3.3; 1.2–8.9, p=0.02), configuration other than brachiobasilic/brachiocephalic autogenous access (3.4; 1.4–8.3, p=0.009), and ≥2 prior access attempts (4.1; 1.6–10.4, p=0.004). Brachiocephalic access configuration (0.2; 0.04–0.8, p =0.02), and autogenous vein conduit (0.2; 0.06–0.58, p=0.004) were predictors of improved bypass patency. All-cause mortality was 28% and 79% at 1 and 5 years, respectively. Multi-variable predictors of mortality were age > 40 (8.3; 2.5–33.3, p =0.0004), grade 3 ischemia (2.6; 1.5–4.6, p=0.0008), complication from DRIL (2.4; 1.3–4.5, p=0.004), and smoking history (2.2; 1.3–4, p=0.007). Patients with no prior access attempts had lower predicted mortality (0.5; 0.3–0.9, p=0.02). Conclusion The DRIL procedure effectively improves distal perfusion and reverses the symptoms of ARHI while salvaging the access, but the long-term survival of these patients is poor. Given the poor survival, pre-operative risk stratification is critical. Patients at high risk for DRIL failure and mortality may be best served with alternate remedial procedures.

Management and outcomes of dialysis access-associated steal syndrome

“…However, our mortality rate (6.8%) was higher than in previous reports. 12 We had four mortalities within 30 days in the DRIL group; two were postoperative cardiac events, and two occurred after discharge with an unknown cause of death. We typically perform our DRIL procedures under either arm block or monitored anesthesia care with local anesthesia (both perioperative deaths were performed under local anesthesia) to minimize cardiopulmonary stress.…”

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

“…10,27,28 Despite concerns regarding the need for ligation of an axial artery and dependence of a limb on an arterial bypass, numerous large studies have shown graft thrombosis is a very rare event, with primary patency of 86% to 100% at 1 year and 78% 6 5% to 96.9% at 5 years. 10,13,19,27,28 In addition, Scali et al 13 found in the largest reported series of 134 DRILs that three of the eight brachial artery bypasses that thrombosed during follow-up were asymptomatic, and the remainder were managed with repeat DRIL, without significant tissue loss or functional deficit. Findings in this study were consistent with previously published reports, with secondary patency of the brachial artery bypass component of the DRIL of 100% at 3-year follow-up and no documented episodes of brachial artery bypass thrombosis.…”

“…7,9 The DRIL procedure has been shown to be a durable intervention for ARHI, and multiple recent large series have reported excellent long-term secondary patency rates approaching 80% at 5 years. [10][11][12][13] In addition to the DRIL, several other procedures have emerged as alternatives for the management of ARHI, including revision using distal inflow (RUDI), 14 proximalization of arterial inflow (PAI), 15 conventional banding of the venous outflow, 16 the minimally invasive limited ligation endoluminal-assisted revision procedure, 17 and transposition of the radial artery. 18 The RUDI, in particular, has shown promise in preliminary studies as a simple and effective therapeutic option for the treatment of ARHI.…”

Prevention, Diagnosis and Management of Steal Syndrome

“…Satisfactory graft patency has been reported from specialized centers. 19,20 Nonetheless, DRIL is a major surgery that potentially leads to substantial morbidities. 20 It is a good option for younger, medically healthier patients with reasonable brachial artery condition.…”

“…19,20 Nonetheless, DRIL is a major surgery that potentially leads to substantial morbidities. 20 It is a good option for younger, medically healthier patients with reasonable brachial artery condition. DRIL may not be a favorable option for patients that are medically frail, with small and calcified brachial artery or extensive severe obstruction of hand and forearm arteries.…”