Distal Revascularization and Interval Ligation “DRIL” Procedure in Steal Syndrome Management in Pediatrics and Young Adults on Hemodialysis

Background: The ischemic steal syndrome is a rare but serious complication of the arteriovenous hemodialysis access (AVA) because it can involve the functional prognosis of the limb. Therapeutic alternatives as (banding or fistula ligation) to manage this issue have proved to be entirely unsatisfactory because of loss of the recently created access through ligation or attempted salvage by increasing resistance within the fistula.

Objective: This study aimed to determine the results of the DRIL technique in the treatment of steal syndrome in young hemodialyzed patients.

Materials and Methods: A retrospective study (2010–2019) was conducted on 10 patients complaining of steal syndrome with ages ranged from 13 to 45 years (mean = 27 years) after obtaining written informed consent. Five patients were females (50%) and five (50%) were males. These patients have undergone DRIL procedure in Thoracic and Cardiovascular Surgery Department at Abderrahmen Mami Hospitals. Preprocedural Doppler ultrasound and angiography were performed in all cases. Patient characters, risk factors, types of fistulae, and indications for surgery were listed. The clinical outcomes of the procedure, AVA, and bypass graft patency were determined as well.

Results: The AVA was proximally located in the arm (brachiocephalic in seven cases and brachiobasilic in three cases). Steal symptoms comprised hand ache, neurologic deficiency, and gangrenous ulcerations. The procedure was technically effective in all patients. Prompt and total pain release was accomplished in 9 (90%) of the 10 patients. One patient (10%) with gangrene later underwent transmetacarpal amputation. During follow-up (range: 24 ± 3 months) hemodialysis was performed continuously using the AVA in all patients. No AVA thrombosis had happened in all patients post-DRIL. Significant difference was found between diabetes and occurrence of steal syndrome (p < 0.05).

Conclusion: DRIL technique is a secure and efficient method to manage steal syndrome in pediatrics and in young adults. AVA durability is not influenced by this procedure. Preoperative angiography pre and post-AVA manual compression is essential for adequate patients’ selection in which benefit will be gained mostly by the performed procedure.

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Artikel online veröffentlicht:
14. Dezember 2021