Midterm outcome after the distal revascularization and interval ligation (DRIL) procedure

Abstract

The DRIL procedure safely and effectively relieves the symptoms of severe access-related hand ischemia while preserving the access. The midterm results suggest that the DRIL bypasses are durable, although long-term graft surveillance may be justified given the observed failures.

Distal Revascularization and Interval Ligation: A Primer for the Vascular and Interventional Radiologist

“…1 The native brachial artery is ligated just after the takeoff of the dialysis access. The distal anastomosis of the DRIL bypass is inserted in the native artery in an end-to-end or end-to-side fashion just distally to the ligated native artery (Figs.…”

“…[1][2][3][4][5][6][7] Dialysis-associated steal syndrome occurs when distal arterial ischemic symptoms develop secondary to the placement of arteriovenous grafts or fistulas. In essence, the more proximal dialysis access ''steals'' the arterial inflow through the low-resistance shunt, creating arterial insufficiency to the extremity, which can lead to symptoms of claudication, numbness, paresthesia, motor dysfunction, pain, or tissue loss.…”

“…8 The development of hand ischemia that requires further surgical intervention is between 5 to 8%. [1][2][3][4][5][6][7]9,10 Many surgical options have been described for the treatment of dialysis-associated arterial steal syndrome. The distal revascularization interval ligation (DRIL) procedure has quickly become a desirable treatment option for dialysis-associated arterial steal syndrome.…”

“…A history of access-related hand ischemia and diabetes are two of the strongest predictors for the development of subsequent arterial insufficiency to the extremity. 1 Steal is more likely when the access is placed above the brachial artery trifurcation. 9,10 Other risk factors such as advanced age, female sex, peripheral arterial occlusive disease, large conduits such as femoral or popliteal veins, or history of multiple prior procedures have also been described.…”

“…9,10 Other risk factors such as advanced age, female sex, peripheral arterial occlusive disease, large conduits such as femoral or popliteal veins, or history of multiple prior procedures have also been described. 1,[3][4][5]11 During the placement of the initial dialysis access, an intraoperative digital-brachial index of less than 0.45 is also a risk factor for the subsequent development of hand ischemia. 12 The clinical workup for patients suspected of having arterial steal syndrome includes a physical examination, sonographic Doppler interrogation, and angiography.…”