Proximalization of the arterial inflow: a new technique to treat access-related ischemia

Arteriovenous access-related ischemia is an uncommon but serious and occasionally devastating complication. Distal revascularization-interval ligation (DRIL) has been established as a standard treatment procedure; however, an axial artery is ligated and the distal perfusion is maintained by the construction of an arterial bypass. Because such an approach, in principle, appears undesirable, we developed and applied an alternative technique referred to as proximalization of the arterial inflow (PAI). This procedure converts the arterial supply of the arteriovenous access to a more proximal artery with higher capacity by using a small-caliber polytetrafluoroethylene graft as a feeder.

From January 1999 to June 2005, the PAI technique was applied in 30 patients. The indication was seen in patients with severe distal ischemia who had a flow volume rate of <800 mL/min in a native fistula and <1000 mL/min in prosthetic access.

Pain was the dominant symptom of ischemia in most patients before surgery. In 37%, a tissue loss was observed. The symptoms of access-related ischemia disappeared completely in 84% of patients and improved significantly in 16%. The significant hemodynamic improvement was confirmed by an increase of the intraoperatively measured mean distal arterial pressure from 32 +/- 9 mm Hg to 63 +/- 8 mm Hg. The digital-brachial index increased from 0.40 +/- 0.10 to 0.83 +/- 0.07. The mean access flow rate was 658 +/- 80 mL/min after PAI and did not differ significantly with the preoperative value (634 +/- 181 mL/min). With a mean follow-up interval of 26.1 +/-19.1 months, the primary and secondary patency rates were, respectively, 87% and 90% at 1 year and 67% and 78% at 3 years.

The PAI procedure represents a well-suited alternative to the DRIL technique for the treatment of patients who develop ischemia after creation of an arteriovenous access. Results for access salvage and disappearance of ischemic symptoms are equivalent to the DRIL technique. In contrast to the DRIL procedure, the PAI technique preserves the natural arterial pathway. Hence, PAI is preferable for surgeons who are reluctant to ligate an axial artery and are concerned about potentially disastrous consequences.