TITLE: Distal Revascularization and Interval Ligation for the Management of Dialysis Access Steal Syndrome.
BACKGROUND: Treatment options for dialysis access steal syndrome (DASS) include distal revascularization with interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. This study examines the efficacy of DRIL in treating DASS and reports short-term bypass patency, access patency, and wound infection rates.
METHODS: A retrospective analysis was performed on adults diagnosed with DASS following hemo-dialysis access creation who underwent DRIL procedures between January 1, 2009 and May 11, 2017. Patients <18 years and those with lower extremity accesses or HeRO grafts that developed DASS were excluded. Data was obtained using electronic medical records and analyzed using SPSS software. Residual steal was defined as reintervention for DASS within 60 days of DRIL. Recurrent steal was defined as reintervention beyond 60 days.
RESULTS: 89 DRIL procedures were performed for correction of DASS. Population included 59.6% female (n=53), 47.2% current/former smokers (n=42), 76.4% diabetic (n=68), and 79.8% AVF (n=71). Symptom resolution was complete for 69.7% (n=62) and partial for 25.8% (n=23), with no improvement in 4.5% (n=4). Following DRIL, mean DBI improved from 0.43 to 0.67 (p=0.002). Mean steal classification improved from 3.04 to 0.64 (p<0.001). Five patients required a subsequent procedure for DASS symptoms - three for residual steal and two for recurrent steal. Bypass patency at 6 months post DRIL was 93.3% (n=83) primary, 97.8% (n=87) primary-assisted, and 100% (n=89) secondary patency. Access patency at 6 months post DRIL was 78.7% (n=70) primary, 91% (n=81) primary-assisted, and 94.4% (n=84) secondary. 21 patients (23.5%) had 24 cases of surgical site infections, with 70.8% (n=17) occurring at the saphenectomy site. Wound infections resolved within 60 days post-operatively in 23 out of 24 patients.
CONCLUSIONS:DRIL is highly effective in relieving symptoms of DASS and has excellent rates of short-term access and bypass patency. However, consideration must be given to the high wound infection rate and the potential need for subsequent procedures.
SOURCE: Alie-Cusson FS, Bhat K, Ramchandani J, et al. Distal Revascularization and Interval Ligation for the Management of Dialysis Access Steal Syndrome[J]. Ann Vasc Surg, 2021, DOI: 10.1016/j.avsg.2021.01.102.
背景：透析通路盗窃综合征（DASS）的治疗选择包括联合间隔结扎术（DRIL）的远端血运重建、动脉入路（PAI）的近端化、通路绑扎和通路结扎。这项研究检查了DRIL治疗DASS的功效，并报告了短期旁路通畅，通路通畅和伤口感染率。
方法：对2009年1月1日至2017年5月11日接受DRIL程序进行血液透析通路建立并被诊断为DASS的成年人进行回顾性分析。<18岁的患者以及下肢通路或HeRO移植物形成DASS的患者为排除在外。使用电子病历获取数据，并使用SPSS软件进行分析。残留盗窃的定义是在DRIL的60天内对DASS进行重新干预。经常性盗窃被定义为超过60天的再次干预。
结果：进行了89次DRIL手术以纠正DASS。人口中包括59.6％的女性（n = 53），47.2％的当前吸烟者/前吸烟者（n = 42），76.4％的糖尿病患者（n = 68）和79.8％的AVF（n = 71）。症状缓解的完成率为69.7％（n = 62），部分为25.8％（n = 23），没有改善为4.5％（n = 4）。在DRIL之后，平均DBI从0.43提高到0.67（p = 0.002）。平均窃血分类从3.04提高到0.64（p <0.001）。五名患者需要针对DASS症状进行后续手术-三名残余盗窃和两名复发盗窃。 DRIL后6个月的一期旁路通畅率为93.3％（n = 83），辅助一期为97.8％（n = 87），二期为100％（n = 89）。 DRIL后6个月的一期手术通畅率为78.7％（n = 70），辅助一期为91％（n = 81），二期为94.4％（n = 84）。 21名患者（23.5％）发生了24例外科手术部位感染，其中70.8％（n = 17）发生在大隐静脉切除部位。 24例患者中有23例在术后60天内伤口感染得到解决。
结论：DRIL在缓解DASS症状方面非常有效，并且极好的短期通畅和旁路通畅性。但是，必须考虑高伤口感染率以及后续手术的潜在需求。
启发：窃血综合征发生率较低，对于特殊患者（糖尿病、血管钙化等），需要特别关注DASS的发生，及时予以处理。同样需要注意内瘘的设计，减少窃血综合征的发生。
