Distal Revascularization and Interval Ligation for the Management of Dialysis Access Steal Syndrome

Background: Treatment options for dialysis access steal syndrome (DASS) include distal revascularization with interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. This study examines the efficacy of DRIL in treating DASS and repor ts shor t-term bypass patency, access patency, and wound infection rates. Methods: A retrospective analysis was performed on adults diagnosed with DASS following hemo-dialysis access creation who underwent DRIL procedures between January 1, 2009 and May 11, 2017. Patients < 18 years and those with lower extremity accesses or HeRO grafts that developed DASS were excluded. Data was obtained using electronic medical records and analyzed using SPSS software. Residual steal was defined as reintervention for DASS within 60 days of DRIL. Recurrent steal was defined as reintervention beyond 60 days. Results: Eighty-nine DRIL procedures were performed for correction of DASS. Population included 59.6% female ( n = 53), 47.2% current/former smokers ( n = 42), 76.4% diabetic ( n = 68), and 79.8% AVF ( n = 71). Symptom resolution was complete for 69.7% ( n = 62), and partial for 25.8% ( n = 23), with no improvement in 4.5% ( n = 4). Following DRIL, mean DBI improved from 0.43 to 0.67 ( P = 0.002). Mean steal classification improved from 3.04 to 0.64 ( P < 0.001). Five patients required a subsequent procedure for DASS symptoms - 3 for residual steal and 2 for recurrent steal. Bypass patency at 6 months post DRIL was 93.3% ( n = 83) primary, 97.8% ( n = 87) primary-assisted, and 100% ( n = 89) secondary patency. Access patency at 6 months post DRIL was 78.7% ( n = 70) primary, 91% ( n = 81) primary-assisted, and 94.4% ( n = 84) secondary. Twenty-one patients (23.5%) had 24 cases of surgical site infections, with 70.8% ( n = 17) occurring at the saphenectomy site. Wound infections re-solved within 60 days postoperatively in 23 out of 24 patients. Conclusions: DRIL is highly effective in relieving symptoms of DASS and has excellent rates of short-term access and bypass patency. However, consideration must be given to the high wound infection rate and the potential need for subsequent procedures.