Distal revascularization and interval ligation: a primer for the vascular and interventional radiologist

Abstract

Dialysis-associated steal syndrome is a clinically significant complication associated with the creation of dialysis grafts or fistulae. The distal revascularization and interval ligation (DRIL) procedure is a surgical procedure, which has been used to treat patients with hand ischemia secondary to arterial "steal" from dialysis accesses. This article will review the dialysis-associated steal syndrome and the history, anatomy, and clinical results of the DRIL procedure.

Keywords: DRIL; arterial steal; dialysis; distal revascularization and interval ligation; hand ischemia.

Figure 1

Angiogram of the left upper extremity performed through a groin puncture. (A) Arterial inflow is seen in the feeding brachial artery and prompt filling of the brachiocephalic fistula. (B) Delayed image shows very little antegrade flow down the forearm vessels. (C) When the fistula is manually compressed, there is significantly better perfusion of the forearm, suggesting a significant amount of dialysis access “steal.”

Figure 2

(A) An illustration of the normal preoperative anatomy of a brachiocephalic fistula. The arterial inflow from the proximal native brachial artery (P) and the native artery just distal to the take off of the fistula (D) are indicated. The dialysis access (DA) is also illustrated. (B) An illustration of the distal revascularization and interval ligation (DRIL) procedure anatomy shows the native artery has been ligated just distal to the take off of the dialysis access (DA). The bypass conduit from the native brachial artery to the brachial artery just distal to the ligation of the native artery is demonstrated (diamond pattern).

Figure 3

The angiographic anatomy of a typical distal revascularization and interval ligation (DRIL) bypass. An angiogram was performed after accessing the brachiocephalic fistula in a retrograde fashion. (A) The initial image shows the catheter entering the dialysis fistula and the catheter tip is in the native brachial artery. (B) The catheter was advanced into the DRIL bypass showing opacification of the bypass vein graft. (C) With the catheter tip at the distal anastomosis, arterial inflow via the ulnar artery and interosseous artery are demonstrated. The radial artery is occluded proximally. (D) The distal runoff to the hand shows the ulnar artery is the dominant supply to the hand.

Figure 4

An illustration of the revision using distal inflow (RUDI) procedure. The proximal arterial inflow (P) and the artery distal (D) to the dialysis access (DA) are shown. The dialysis access (DA) is ligated and a new conduit is made from a small artery in the forearm to the dialysis access.