Mid-term Outcome of the DRIL Procedure

Background: The distal revascularization and interval ligation (DRIL) procedure has evolved as an alternative to ligation for patients with severe (grade 3) access-related ischemia. Although limited, the initial reports have suggested that the technique relieves the precipitating symptoms and salvages the access. The longer-term durability of the procedure remains poorly defined despite the importance of the brachiobrachial artery bypass on hand perfusion. This study was designed to review our experience with the DRIL procedure and objectively define its mid-term outcome.
Methods: A retrospective review all pts undergoing the DRIL procedure was performed. The diagnosis of severe ischemia was made based upon clinical presentation with noninvasive testing and arteriography used selectively to confirm the diagnosis and/or treat any potential inflow lesions respectively. The choice between DRIL and access ligation was based upon the quality of the access, comorbidities, future access options, and quality of the conduit. The conduit for the DRIL was selected based upon noninvasive imaging (saphenous > arm, diameter ≥ 3 mm). The proximal anastomosis for the DRIL was positioned > 7 cm from the anastomosis for the access. The brachiobrachial grafts were surveyed (pressure measurements, graft scans) q 3 mos for the first year then q 6 mos thereafter. Remedial treatment was performed for recurrent hand symptoms, significant decreases in the arterial pressures, and/or abnormal grafts scans.
Results: 58 pts (female - 64%, age 58 ± 13 (SD)) underwent 63 DRIL procedures during the study dates (2/98 - 8/07). In contrast, 41 pts underwent access ligation for severe hand ischemia during the same interval. The symptoms precipitating the DRIL included paresthesia (43%), motor dysfunction (28%), tissue loss (12%), rest pain (3%) and other (14%). The DRIL was required < 1 day post access in 20%, < 7 days post access in 46%, and < 1 mos post access in 73%. The access procedures included: brachiocephalic autogenous - 40%, brachiobasilic autogenous - 33%, brachioaxillary autogenous SFV graft - 20%, other - 7%. Saphenous vein was the conduit used in the majority of cases (71%) with arm vein (16%) and alternative conduits (SFV, PTFE, cadaveric artery/vein) used for the balance. Perioperative mortality rate for the DRIL was 1.7% (cause - sudden death) and the complication rate was 17% (wound - 13%, compartment syndrome - 2%, lower extremity amputation - 2%). Mean followup was 13 mos (range 0 - 66). Symptomatic improvement occurred in 96% with the remaining two pts requiring access ligation for ongoing ischemia. The primary patency rates for the brachiobrachial bypass were 88 ± 6, 72 ± 11, and 65 ± 12 at 1 yr, 2 yrs, and 3 yrs while the corresponding secondary patency rates were 91 ± 6, 86 ± 10, and 78 ± 12.
Conclusions: The DRIL procedure effectively relieves the symptoms of severe access-related hand ischemia while preserving the hemodialysis access. The mid-term results suggest that the brachiobrachial bypass grafts are reasonably durable although long-term graft surveillance may be justified given the observed graft failures.