introduced by Schanzer et al.14 Ligation provides immediate improvement but requires creation of a new access. Banding–plication techniques improve distal perfusion, but it is difficult to determine the required amount of stenosis to eliminate steal while allowing a flow sufficient to sustain patency of the graft. Flow reduction procedures are attractive options in high-flow AV fistulas (>1,500 mL/min).15 In patients with normal flow through their AV fistulas often concomitant arteriosclerotic disease causes insufficient collateral perfusion. In these cases the DRIL procedure is the treatment of choice. With the DRIL a ligature (placed distal to the take-off of the graft) eliminates the reversal of flow, while the bypass (from a point proximal to the inflow to a point just distal to ligation) re-establishes flow to the limb (Fig. 42.1). Recent reports support the efficacy of this technique.16,17 [Q5:

A, B, C, D]

References

 1. Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a superficially created arteriovenous fistula. N Engl J Med. 1966;275:1089-1092.

 2. NKF-DOQI. Clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis. 2001;30(Suppl 1):S137-S181.

 3. Marx AB, Landerman J, Harder FH. Vascular access for hemodialysis. Curr Probl Surg. 1990;27:1-48.

 4. WindusDW.Permanentvascularaccess:anephrologist’sview.AmJKidneyDis.1993;21:457471.

 5. Feldman H, Kobrin S, Wasserstein A. Hemodialysis vascular access morbidity. J Am Soc Nephrol. 1996;7:523-535.

 6. Marston WA, Criado E, Jaque PF, Mauro MA, Burnham SJ, Keagy BA. Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts. J Vasc Surg. 1997;26:373-381.

 7. Gordon IL. Physiology of the arteriovenous fistula. In: Wilson SE, ed. Vascular access, principles and practice. 3rd ed. St. Louis: Mosby; 1996:29-41.

 8. Schanzer H, Scladany M, Haimov M. Treatment of angioaccess-induced ischemia by revascularization. J Vasc Surg. 1992;16:861-866.

 9. Lazarides MK, Staramos DN, Panagopoulos GN, Tzilalis VD, Eleftheriou GJ, Dayantas JN. Indications for surgical treatment of angioaccess-induced arterial steal. J Am Coll Surg. 1998;187:422-426.

10.Wilson SE. Complications of vascular access procedures. In: Wilson SE, ed. Vascular Access, Principles And Practice. 3rd ed. St. Louis: Mosby; 1996:212-224.

11.Bakran A, Mickley V, Passlick-Deetjen J. Management of the Renal Patient, Clinical Algorithms of Vascular Access for Haemodialysis. Lengerich: Pabst Science; 2003:90.

12.Hye RJ, Wolf YG. Ischemic monomelic neuropathy: an under-recognized complication of hemodialysis access. Ann Vasc Surg. 1994;8:578-582.

13.Wixon CL, Mills JL. Hemodynamic basis for the diagnosis and treatment of angioaccessinduced steal syndrome. Adv Vasc Surg. 2000;8:147-159.

14.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. 1988;7: 770-773.

15.Tordoir JH, Dammers R, van der Sande FM. Upper extremity ischemia and hemodialysis vascular access. Eur J Vasc Endovasc Surg. 2004;27:1-5.

16.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;36:250-255.

17.Lazarides MK, Staramos DN, Kopadis G, Maltezos C, Tzilalis VD, Georgiadis GS. Onset of arterial steal following proximal angioaccess: immediate and delayed types. Nephrol Dial Transplant. 2003;18:2387-2390.

Part X

Amputations