HEMODIALYSIS ACCESS INDUCED DISTAL ISCHEMIA; EFFECTIVENESS OF DIFFERENT TYPES OF REVISIONAL SURGERIES

Objectives: Hemodialysis access induced distal ischemia (HAIDI) is not a rare complication of hemodialysis access and may lead to limb loss at any time from creation. Distal Revascularization Interval Ligation (DRIL), Proximalization of Arterial Inflow (PAI), Surgical Banding, Revision Using Distal Inflow (RUDI), Side branch ligation (SBLs) and Distal Radial Artery Ligation (DRAL) all are surgical re-interventions aiming for improving the distal limb flow improving ischemic manifestations as well as maintaining a functioning hemodialysis access. Although DRIL and surgical Banding are well known techniques and their results are well established. RUDI,DRAL and PAI are relatively new surgical interventions for HAIDI treatment. Results of PAI, RUDI, banding, SBL and DRIL are compared in this study as regard resolutions of ischemic manifestations, patency of both the access and the vascular conduit. Methods: All patients attending to Vascular Clinic at Mansoura University Hospital from May 2014 to May 2018 suffering from acute non-thrombotic, subacute non-thrombotic and chronic HAIDI grade 2a- 4b related to the present hemodialysis access were included. Results: 28 patients were exposed to the previously mentioned techniques. 30 procedures were performed. 12 DRIL, 4 RUDI, 2 PAI, 6 surgical Banding and 2 Side Branch Ligations. Two cases underwent DRAL for distal radial artery based AVF and two cases underwent ligation of the fistula for major tissue loss. Mean age was 53.9 years, 57% of patients were female and 64.2% were diabetics. No differences in patient comorbidities among patients in different surgical group. The median postoperative follow up duration for the 30 procedures done was 9.5 (1-24) months with non-significant difference in mean follow up duration among the different surgical groups. As regard the AVF patency immediate closure recorded in two cases that underwent ligation. Of the remaining 28 procedures; AVFs were kept patent all over the follow up periods (3-24 months) in 16 cases (57.1%). While in the remaining 12 cases AVF patency was 100% at 6 months follow up period and 58.3% (7 cases) at 12 months follow up. Patency of the brachial artery bypass graft in the DRIL group was 91.7% during the whole period of follow up. Conduit patency of the RUDI group was 75% and 50% for the PAI group during the whole period of follow up.