• Rashid Usman CMH Lahore Medical College and CMH Hospital Lahore
  • Muhammad Jamil CMH Rawalpindi
  • Aleena Ahmed Khan CMH Lahore Medical College
  • Afnan Talat CMH Lahore Medical College


Background: We aim to share our experience of the efficacy of Distal Revascularization and Interval Ligation (DRIL) in alleviating ischemic symptoms of dialysis access induced steal syndrome (DAISS) while preserving the original access. Methods: In this multicentre study, all consecutive patients with DAISS undergoing DRIL over a period of 3 years were included. Results: A total of 25 DRILs were included. Mean age was 37.8±SD 7.8 years and 52% (n=13) were females. Out of 25 patients; 88% (n=22) had more than one of the following ischemic symptoms: coolness (96%), pain (88%), paresthesia (80%), and discoloration (44%). Significant improvement following DRIL was noted in paraesthesia (86%, p-value 0.00), pain (85%, P value 0.00), coolness (83%, p-value 0.00). There was significant improvement in distal blood flow following DRIL, reflected by increase in the Aggregate Peak Systolic Velocities (PSV) in forearm vessels (PSV aggregate pre-op 39cm/s: PSV aggregate post-op 58 cm/s; p-value 0.01). The cumulative patency of DRIL graft was 96% at 3 months, 84% at 6 months and 76% at 1 year. Conclusion: Distal Revascularization and Interval Ligation significantly improves circulation to the distal limb and reduce ischemic symptoms thus making it a procedure of choice for treatment of DAISS.  Keywords:  Hand ischemia; Arterio-venous fistula; DRIL; Steal syndrome; Dialysis access

Author Biographies

Rashid Usman, CMH Lahore Medical College and CMH Hospital Lahore

Assistant Professor of SurgeryDepartment of SurgeryCMH Lahore Medical College

Muhammad Jamil, CMH Rawalpindi

Professor of SurgeryDepartment of Vascular SurgeryCombined Military HospitalRawalpindi 

Aleena Ahmed Khan, CMH Lahore Medical College

Department of SurgeryCMH Lahore Medical CollegeLahorePakistan

Afnan Talat, CMH Lahore Medical College

Department of SurgeryCMH Lahore Medical CollegeLahorePakistan


Scheltinga MR, Van Hoek F, Bruijninckx CM. Time of onset in hemodialysis access-induced distal ischemia (HAIDI) is related to the access type. Nephrol Dial Transplant 2009;24(10):3198–204.

Tynan-Cuisinier GS, Berman SS. Strategies for predicting and treating access induced ischemic steal syndrome. Eur J Vasc Endovasc Surg 2006;32(3):309–15.

Knox RC, Berman SS, Hughes JD, Gentile AT, Mills JL. Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access. J Vasc Surg 2002;36(2):250–6.

Illig KA, Surowiec S, Shortell CK, Davies MG, Rhodes JM, Green RM. Hemodynamics of distal revascularization-interval ligation. Ann Vasc Surg 2005;19(2):199–207.

Gupta N, Yuo TH, Konig G 4th, Dillavou E, Leers SA, Chaer RA, et al. Treatment strategies of arterial steal after arteriovenous access. J Vas Surg 2011;54(1):162–7.

Leake AE, Winger DG, Leers SA, Gupta N, Dillavou ED. Management and outcomes of dialysis access-associated steal syndrome. J Vas Surg 2015;61(3):754–60.

Kordzadeh A, Garzon LAN, Parsa AD. Revision using distal inflow for the treatment of dialysis access steal syndrome: A systematic review. Ann Vasc Dis 2018;11(4):473–8.

Schanzer H, Schwartz M, Harrington E, Haimov M. Treatment of ischemia due to ‘steal’ by arteriovenous fistula with distal artery ligation and revascularization. J Vasc Surg 1998;7(6):770–3.

Davidson I, Beathard G, Gallieni M, Ross J. The DRIL procedure for arteriovenous access ischemic steal: a controversial approach. J Vasc Access 2017;18(1):1–2.

Keuter XH, Kessels AG, de Haan MH, van der Sander FM, Tordoir JH. Prospective evaluation of ischemia in brachial-basilic and forearm prosthetic arteriovenous fistulas for hemodialysis. Eur J Vasc Endovasc Surg 2008;35(5):619–24.

Huber TS, Brown MP, Seeger JM, Lee WA. Midterm outcome after the distal revascularization and interval ligation (DRIL) procedure. J Vasc Surg 2008;48(4):926–32.

Misskey J, Yang C, MacDonald S, Baxter K, Hsiang Y. A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia. J Vasc Surg 2016;63(6):1574–81.

Loh TM, Bennett ME, Peden EK. Revision using distal inflow is a safe and effective treatment for ischemic steal syndrome and pathologic high flow after access creation. J Vasc Surg 2016;63(2):441–4.

Aimaq R, Katz SG. Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation. J Vasc Surg 2013;57(4):1073–8.

Scali ST, Chang CK, Raghinaru D, Daniels MJ, Beck AW, Feezor RJ, et al. Prediction of graft patency and mortality after distal revascularization and interval ligation for hemodialysis access-related hand ischemia. J Vasc Surg 2013;57(2):451–8.

Hye RJ, Wolf YG. Ischemic monomelic neuropathy: an under recognized complication of hemodialysis access. Ann Vasc Surg 1994;8(6):578–82.

Vaes RH, Tordoir JH, Scheltinga MR. Blood flow dynamics in patients with hemodialysis access-induced hand ischemia. J Vasc Surg 2013;58(2):446–51.

Walz P, Ladowski JS, Hines A. Distal revascularization and interval ligation (DRIL) procedure for the treatment of ischemic steal syndrome after arm arteriovenous fistula. Ann Vasc Surg 2007;21(4):468–73.

Conte MS, Bandyk DF, Clowes AW, Moneta GL, Namini H, Seely L. Risk factors, medical therapies and perioperative events in limb salvage surgery: Observations from the PREVENT iii multicenter trial. J Vasc Surg 2005;42(3):456–64.

Berman SS, Gentile AT, Glickman MH, Mills JL, Hurwitz RL, Westerband A, et al. Distal revascularization-interval ligation for limb salvage and maintenance of dialysis access in ischemic steal syndrome. J Vasc Surg 1997;26(3):393–404