The "DRIL" procedure - A neglected way to treat the "Steal" syndrome of the hemodialysed patient

Background: The ischemic "steal" syndrome complicates angioaccess in a growing number of hemodialysed patients. Until now, operative attempts (fistula ligation or banding) to treat this problem have met with only limited success. Objective: To assess the results of DRIL (distal revascularization-interval ligation) procedure in treating the "steal" syndrome. Methods: A retrospective review (1996-2002) was conducted of all 11 patients who underwent the DRIL procedure in two tertiary care hemodialysis units. Results: Two patients were excluded because of inadequate medical documentation. All of the nine patients remaining suffered from overt atherosclerotic disease, six had diabetic nephropathy and four were smokers. The arteriovenous access, which led to the "steal" syndrome, was proximally located in all (antecubital in 8, thigh area in 1). "Steal" symptoms included hand pain, paraesthesia, neurologic deficits and gangrenous ulcers. DRIL was technically successful in all patients. There were no perioperative deaths. Immediate and complete relief of pain was achieved in eight of the nine patients. One patient with gangrene later required a transmetacarpal amputation. No patient required hand amputation. During follow-up (range 1-26 months) hemodialysis was continued uninterruptedly using the problematic AVA in all patients. Thrombosis occurred in the AVA in only two patients after the DRIL procedure at 9 and 24 months postoperatively, respectively. Three patient deaths were unrelated to the DRIL. Conclusions: In selected patients the DRIL procedure is a safe and effective way to treat the "steal" syndrome. AVA patency is not compromised by this operation. Preoperative angiography, before and after manual compression of the AVA, is crucial for the proper selection of patients who will benefit most from the DRIL procedure.