title: Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access.
abstract: OBJECTIVE
  The treatment of hemodialysis access-induced ischemic steal syndrome is challenging. Despite promising early results with the distal revascularization-interval ligation (DRIL) procedure, the operation has not been widely adopted because of concerns about its complexity and long-term efficacy. The purpose of this report was to determine the efficacy and durability of the DRIL procedure in relieving hand ischemia and in maintaining access patency in the setting of hemodialysis access-induced ischemia.
  
  
  METHODS
  A retrospective review was performed of all patients who underwent the DRIL procedure for access-induced ischemia. Demographic information was compiled, as were data regarding access and bypass patency, limb salvage, and patient survival. Arteriovenous access and brachial artery bypass patency rates were determined with life-table methods.
  
  
  RESULTS
  Between 1995 and 2001, we performed 55 DRIL procedures in 52 patients (35 women and 17 men; mean age, 60.8 years; range, 30 to 86 years). The indications for surgery were ischemic pain in 27 patients, tissue loss in 20 patients, loss of neurologic function in four patients, and pain on hemodialysis in one patient. Most patients (92%) had diabetes. The mean interval from access placement to DRIL was 7.4 months (range, 1 to 84 months). The mean follow-up interval was 16 months (range, 1 to 67 months). The brachial artery bypass primary patency rate was 80% at 4 years, and the arteriovenous access primary patency rate was 83% at 1 year. Forty-seven of 52 patients (90%) had substantial or complete relief of ischemic hand symptoms, and 15 of 20 patients with digital ischemic lesions have healed completely.
  
  
  CONCLUSIONS
  DRIL is a durable and effective procedure that reliably accomplishes the twin goals in the treatment of angioaccess-induced ischemia: persistent relief of hand ischemia and continued access patency.
authors.affiliation: Section of Vascular Surgery, The University of Arizona Health Sciences Center, Tucson, AZ 85724, USA.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Knox
authors.forename: Scott S
authors.initials: SS
authors.lastname: Berman
authors.forename: John D
authors.initials: JD
authors.lastname: Hughes
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Gentile
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Mills
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001132:Arm / Q000098:blood supply*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D003925:Diabetic Angiopathies / Q000150:complications / Q000628:therapy; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000601:surgery*; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy; D015993:Life Tables; D008026:Ligation; D008297:Male; D008875:Middle Aged; D011138:Polytetrafluoroethylene; D006435:Renal Dialysis / Q000009:adverse effects*; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000637:transplantation; D014654:Vascular Patency
chemical_list: D011138:Polytetrafluoroethylene