CHICAGO – The best strategy for access-related hand ischemia is to have a plan in place before it occurs.
"The whole approach for patients at high risk of developing hand ischemia is to think about it preoperatively" and devise a remedial plan, Dr. Thomas S. Huber said at the symposium. "I always tell our trainees and fellows: ‘What are you going to do in 20 minutes when the recovery room nurse says the patient has motor compromise and unbelievable hand pain?’ You have to have a remedial plan."
Access-related hand ischemia (ARHI), or steal syndrome, occurs in just 2% of radial artery–based access procedures, but up to 20% of brachial artery–based access procedures. Roughly half of these events are severe enough to merit remedial treatment. With more than 8 million arterial catheters placed perioperatively in the United States each year and 350,000 patients on dialysis, the numbers add up.
"There are multiple complementary treatment options that you ought to have in your armamentarium," said Dr. Huber, chief of vascular surgery and endovascular therapy, University of Florida Health Science Center, Gainesville, Fla.
"The DRIL has worked remarkably well for us."
The distal revascularization and interval ligation (DRIL) procedure involves a brachial-brachial bypass with ligation of the brachial artery immediately distal to the fistula anastomosis.
Dr. Thomas Huber
In their hands, DRIL significantly increased wrist-brachial and digital-brachial indices (0.31 and 0.25) in 126 patients undergoing 134 procedures from 2002 to 2011 (J. Vasc. Surg. 2013;57:451-8). Ischemic symptoms were relieved in 82% of patients, and the index access was salvaged in 85%.
"Really, the DRIL procedure has almost no impact on the success of the access," Dr. Huber said. "For those patients [in which] we perform the DRIL [procedure] before their access is mature, our maturation rate is comparable whether we do the DRIL or not."
Primary patency was 95% at 1 year and 78% at 5 years. The overall complication rate, driven mostly by wound complications, reached 27%, and 30-day mortality was 2%.
"I sheepishly stand before you to say that our mortality rate for all our access procedures is about 3%," he said. "It’s a pretty minimal operation so, my gosh, how could that possibly be? But it’s a very morbid population. In our country, the 1-year mortality rate for people starting dialysis is right at 23%. So they’re older, sicker patients, with a limited life expectancy."
All-cause mortality in the series was 28% and 79% at 1 and 5 years, respectively. Age greater than 40 years, grade 3 ischemia, any DRIL complication, and smoking history were all significant multivariable predictors of mortality.
An extensive list of clinical ARHI predictors has been identified, such as female sex, advanced age, and large conduits, but none reliably predicts when access should not be attempted, Dr. Huber said. The use of preoperative noninvasive imaging also is helpful to identify patients at risk for ARHI, but the predictive values have not been sufficient to avoid attempting the access procedure.
In their experience, presentation of hand ischemia has been trimodal, with a third of patients presenting within 7 days of their index procedure, a third within 7-30 days, and a third thereafter. A weak ulnar or radial pulse on physical exam after creating a dialysis access has misled some to dismiss hand ischemia, while a prior episode of ARHI is a red flag for high risk of recurrence.
"I would contend that the incidence of developing hand ischemia on the right arm if you had it on the left arm is about 100%," dispelling the concept of simply ligating the access that led to hand ischemia and then repositioning it on the contralateral extremity, Dr. Huber said.
Their overall treatment approach for ARHI in poor operative-risk patients, particularly older patients with a prosthetic access, is to proceed to ligation. Good-risk patients undergo some type of inflow assessment, and if a significant inflow lesion is present, it is corrected, usually at the same time as the DRIL, he said. Proximalization of the arterial inflow would be considered for patients with persistent symptoms and no available conduit, while DRIL is the go-to procedure for those with available vein conduits more than 3 cm in diameter, preferably the greater saphenous vein.
Noticeably absent in their algorithm is some type of flow-limiting strategy, such as banding, and the revision using distal inflow procedure. These approaches may have a role, but the published literature is somewhat inconclusive, Dr. Huber said at the symposium, sponsored by Northwestern University.
Despite the overwhelming number of Americans on dialysis, less than 300 DRIL cases have been reported in the literature since its introduction in 1988. The University of Florida experience has been corroborated by a recent report of complete symptom resolution in 82% of 81 DRIL procedures, with a 17% complication rate, and five-year access and bypass survival rates of 56% and 97% (J. Vasc. Surg. 2013;54:1073-8).