Side branch ligation for haemodialysis-access-induced distal ischaemia

Chronic hand ischaemia is occasionally observed in haemodialysis patients with a brachiocephalic fistula using the Gracz technique. Open venous side branches of the access may contribute to lower peripheral perfusion pressures. This study reports on the effects of access side branch ligation (SBL) on ischaemia in patients with haemodialysis access induced distal ischaemia (HAIDI).

Hand ischaemia was quantified using a published questionnaire (HIQ, minimal 0 points: no ischaemia, maximal 500: excruciating ischaemia). Finger pressures (P(dig), mmHg), digital brachial index (DBI) and access flow were measured before and after SBL.

Twenty-two patients were operated for grade 2-4 HAIDI during 7 years, and 12 underwent SBL (as single procedure n = 5, preceeding banding/DRIL n = 7). Hand ischaemia was attenuated after SBL only (n = 5, HIQ 216 ± 39 vs. 73 ± 26, P = 0.04). A 25% increase was observed in both P(dig) (n = 12, before SBL: 57 ± 8 mmHg, after: 72 ± 8 mmHg, P = 0.012) and DBI (before SBL: 0.49 ± 0.06, after: 0.61 ± 0.04, P = 0.006). Access flow did not change. All patients successfully resumed dialysis.

SBL may be effective as single or adjunctive surgical procedure in the treatment of HAIDI in the presence of a Gracz fistula.