Treatment of Hand Ischemia Following Angioaccess Surgery Using the Distal Revascularization Interval-Ligation Technique with Preservation of Vascular Access: Description of an 18-Case Series

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

“…Contrary to some reports, 32 it is a common problem and should be considered/anticipated pre-operatively in certain subsets of 36 5 100% (mean 7 mos) 83% -improved/resolved 100% (mean 7 mos) NA Stierli 37 6 100% (6-24 mos) 100% -improved/resolved 100% (6-24 mos) NA Knox 11 55 1°-80% @ 4 yrs (life table) 90% -improved/resolved 71% @ 3 yrs (life table) 56% @ 4 yrs (life table) Lazarides 12 23 69% @ 1 yr 100% -resolved NA NA Diehl 38 13 83% @ 2 yrs 100% -improved 57% -resolved 71% @ 2 yrs NA Korzets 39 9 100% (mean 12 mos) 100% -resolved 78% (mean 12 mos) NA Sessa 13 18 patients. The risk factors are fairly extensive and include advanced age, female gender, diabetes, peripheral arterial occlusive disease, large conduits (ie, femoral/popliteal vein), and multiple prior procedures.…”

“…The DRIL procedure has evolved as the optimal remedial treatment and has been reported to effectively reverse the hand ischemia and preserve the access. [10][11][12][13][14] However, the overall published experience with this procedure is limited and concerns have been raised about the complexity of the procedure, the necessity of ligating the brachial artery, and the long-term patency rates of the bypass. This study was designed to review our institutional experience with the DRIL procedure and objectively define its midterm outcome.…”

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.…”

“…Many authors suggest that a short bypass, originating only a few centimetres proximal to the AVF may be adequate. 11,13,16 This study was undertaken to test the hypothesis that a brachial level AVF generates a zone of low arterial blood pressure in the brachial artery near the AVF origin. Such a zone of low pressure might extend over a distance within the brachial artery, suggesting that optimal inflow for the DRIL procedure should be taken at a more proximal level than previously recommended.…”

Stenotic ligature: a simple technique for managing distal hypoperfusion ischemic syndrome following arteriovenous fistulas

“…The surgical techniques described to date are distal revascularization and interval ligation (DRIL) (7,8), proximalization of the arterial inflow (9), the revision using distal inflow technique (RUDI) (10), banding (11) and plication (12) techniques. Banding is a simple technique to reduce fistula flow however it is associated with thrombosis of the AVF (2).…”