Distal Revascularization with Interval ligation (DRIL) – An Extended Indication and Technical Details

Background: Mature autogenous arteriovenous fistula(AVF) seems to be the best way to access the circulation for chronic hemodialysis in patients with end stage renal disease(ESRD), but in some cases steal can occur in relation to these fistulas and resulted in distal ischemia manifested as attacks of sever ischemic pain during dialysis sessions (that may mandate discontinuation of the session) which may progresses to digital ischemic rest pain, digital ulcers or gangrene. And in some cases long standing peripheral nerve ischemia can occur and manifests as a progressive atrophy of forearm and hand muscles with progressive weakening of hand grip. Over decades DRIL operation was described as a definitive treatment to cure this ischemic manifestation with preservation of the fistula, but criteria for patient selection, fine technical details and the spectrum of indications were lacking in these previous reports.

Aim of the Work: The aim of this study is to define criteria for selection of cases for whom DRIL operation can be applied with good outcome, test the efficacy of this procedure to treat fistula induced distal ischemic neuropathy and achieving partial or complete nerve recovery. Along with description of the fine technical details during surgery.

Materials and Methods: Twelve patients were enrolled in this study, all of them were having mature brachial artery based AVF for chronic hemodialysis with manifestations of distal ischemia caused by steal through the fistula. They were examined clinically and by duplex ultrasound, routine lab. and cardiac investigations were done. Nerve conduction studies were done for cases with suspected ischemic neuropathy. Surgery was planned for all of them where a vein was used as a bypass graft after ligation of the artery just distal to the fistula and patients were followed up over the next six months.

Resuls: DRIL operation was successfully applied to all selected patient with almost complete cure of ischemic manifestations and, surprisingly, a progressive recovery of severely damaged nerves, in cases presented with sever ischemic neuropathy, as the patients regained a near normal muscle mass and hand grip. All grafts were patent at the end of the follow up (100% primary patency).

Conclusion: Beside being an ideal solution for a selected cohort of patients suffering from fistula induced critical hand ischemia, DRIL operation offers an excellent treatment option for those suffering from fistula induced delayed ischemic neuropathy especially in its sever form.