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Prophylactic Distal Revascularization with Interval Ligation (DRIL) with Simultaneous Arteriovenous Fistula Creation in Patients with Previous Steal Syndrome
Andrew E. Leake, MD1, Steven A. Leers, MD1, Thomas Reifsnyder, MD2, Ellen D. Dillavou, MD1.
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2John Hopkins University, Baltimore, MD, USA.
Objectives- Dialysis access-related ischemic steal syndrome is a common dialysis access complication. When severe, manifestations include rest pain, hand dysfunction and tissue loss. The affected extremity is usually abandoned after a diagnosis of steal syndrome and patients are often left catheter-dependent. The pre-emptive distal revascularization with interval ligation (DRIL) has been described in patients with previous steal syndrome who are deemed high-risk for recurrence. We present our experience with the prophylactic DRIL performed simultaneously with arteriovenous fistula (AVF) creation to prevent the recurrence of access-related steal syndrome.
Methods- After IRB approval, a retrospective review was performed at two major academic medical institutions, identifying patients who underwent prophylactic DRIL procedures with simultaneous AVF creation from July 2010 to July 2013. Demographics, technical details and patient outcomes were obtained.
Results- Five patients underwent simultaneous DRIL/AVF placement. All patients previously experienced steal, and subsequent access ligation. Three patients were female, with a mean age of 64 (range 39-80) years. All patients had peripheral vascular disease, diabetes mellitus and end stage renal disease on dialysis. Mean number of previous access procedures was 2.6 per patient. All new AVF were brachial based and placed on the same side as the patient’s previous episode of steal. Fistula types included three basilic vein transpositions, one brachial vein transposition and one brachial artery to axillary vein graft utilizing translocated femoral vein. DRIL bypass conduits included saphenous vein (3) and basilic vein (2). There were no 30-day complications or development of steal syndrome. At the time of last follow up (Mean 244 days), all AVF were functional and DRILs remained patent. One patient died >30 days after procedure, unrelated to access placement.
Conclusions- In patients with previous ischemic steal, a prophylactic DRIL with simultaneous AVF creation can allow use of the same extremity without recurrent symptoms. Larger studies are needed to better define patients that are at high-risk of developing access-related steal syndrome and would therefore benefit from a prophylactic DRIL at the time of AVF creation.
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