The treatment goals for access related hand ischemia (ARHI) are to reverse symptoms and salvage the access. Many procedures have been described, but the optimal treatment strategy remains unresolved. In an effort to guide clinical decision making, this study was undertaken to document our outcomes for distal revascularization and interval ligation (DRIL) and identify predictors of bypass patency and patient mortality.
A retrospective review was performed of all patients who underwent DRIL at the University of Florida from 2002–2011. Diagnosis of ARHI was based primarily upon clinical symptoms with non-invasive studies used to corroborate in equivocal cases. Patient demographics, procedure-outcome variables and re-interventions were recorded. Bypass patency and mortality were estimated using cumulative incidence and Kaplan-Meier methodology, respectively. Cumulative incidence and Cox regression analysis were performed to determine predictors of bypass patency and mortality, respectively.
134 DRILs were performed in 126 patients (age 57±12yrs (mean±SD)) following brachial artery-based access. The post-operative complication rate was 27% (19%-wound), and 30-day mortality was 2%. The wrist/brachial (WBI) and digital/brachial (DBI) indices increased 0.31±0.25 and 0.25±0.29, respectively. Symptoms resolved in 82% of patients, and 85% continued to use their access. Cumulative incidences of loss of primary and primary-assisted patency rates were 5±2%, 4±2% and 22±5%, 18±5% at 1 and 5 years, respectively with a mean follow-up of 14.8 months. Univariate predictors of primary patency failure were DRIL complications (3.3; 1.2–8.9, p=0.02), configuration other than brachiobasilic/brachiocephalic autogenous access (3.4; 1.4–8.3, p=0.009), and ≥2 prior access attempts (4.1; 1.6–10.4, p=0.004). Brachiocephalic access configuration (0.2; 0.04–0.8, p =0.02), and autogenous vein conduit (0.2; 0.06–0.58, p=0.004) were predictors of improved bypass patency. All-cause mortality was 28% and 79% at 1 and 5 years, respectively. Multi-variable predictors of mortality were age > 40 (8.3; 2.5–33.3, p =0.0004), grade 3 ischemia (2.6; 1.5–4.6, p=0.0008), complication from DRIL (2.4; 1.3–4.5, p=0.004), and smoking history (2.2; 1.3–4, p=0.007). Patients with no prior access attempts had lower predicted mortality (0.5; 0.3–0.9, p=0.02).
The DRIL procedure effectively improves distal perfusion and reverses the symptoms of ARHI while salvaging the access, but the long-term survival of these patients is poor. Given the poor survival, pre-operative risk stratification is critical. Patients at high risk for DRIL failure and mortality may be best served with alternate remedial procedures.