Revision using distal inflow versus distal revascularization and interval ligation in management of dialysis access steal syndrome

Objective
Dialysis access steal syndrome (DASS) is a serious limb-threatening complication of arteriovenous access for dialysis. Redirection of arterial inflow includes distal revascularization and interval ligation (DRIL) and revision using distal inflow (RUDI); both allow improvement of ischemic symptoms while preserving the access. Although outcomes with the DRIL are well established, experience with the RUDI for DASS remains promising.
Aim
The purpose of this study was to evaluate the efficacy and outcome of RUDI in comparison with DRIL in the management of DASS.
Patients and methods
The present single-center randomized clinical study recruited 65 patients presented with DASS. A total of 40 patients presented with stage III and stage IV DASS during the study period. RUDI was performed in 19 patients and DRIL in 21 patients. The study was conducted at Vascular Surgery Departments, Zagazig University Hospitals, Egypt, from May 2016 to January 2021. The primary outcome in the present study was clinical symptom resolution and successful dialysis without pain. Other outcome parameters included duplex assessment of dialysis circuit flow rate and distal vessel peak systolic velocity, complications, primary patency, assisted primary patency, secondary patency, cumulative primary, and assisted primary patency as well as intervention-free survival during 12-month follow-up.
Results
In the DRIL group, patient demographics were as follows: mean age was 59.3 years, 16 were females, 13 were diabetics, and 15 were hypertensives, whereas in the RUDI group, the mean age was 56.9 years, 13 were females, 15 were diabetics, and 13 were hypertensives. There were no preoperative differences in patient comorbidities between the RUDI and DRIL. Indications for intervention were tissue loss (30%) or ischemic rest pain (70%). Resolution of ischemic symptoms with successful dialysis without pain, which occurred in 89.5% of RUDI patients and in 85.7% of DRIL patients (=0.72), with regaining of radial pulsations. Ischemic rest pain persisted in two RUDI patients and three DRIL patients, who required access ligation to save the limb from progressive tissue loss. Two DRIL and three RUDI patients required partial or complete digital amputation after successful revascularization. Primary patency rates between RUDI and DRIL groups at 12 months (63.2 vs. 61.9%) were comparable (=0.99), in addition to the primary-assisted patency rates at 12 months (73.7 vs. 71.4%; =0.87). Secondary patency rates between RUDI and DRIL groups at 12 months (78.9 vs. 76.2%) were also comparable (=0.83). Wound complications were documented in five (17%) patients, including two patients in DRIL and three patients in RUDI; all resolved with conservative management and antibiotics.
Conclusion
RUDI is a good alternative to DRIL in managing severe DASS symptoms and access preservation. RUDI avoids DRIL’s complexity and risks with similar symptom resolution, patency, and complication rates.