Berman S S, Gentile A T, Glickman M H, Mills J L, Hurwitz R L, Westerband A, Marek J M, Hunter G C, McEnroe C S, Fogle M A, Stokes G K
Section of Vascular Surgery, University of Arizona Health Sciences Center, Tucson 85724-5072, USA.
J Vasc Surg. 1997 Sep;26(3):393-402; discussion 402-4. doi: 10.1016/s0741-5214(97)70032-6.
Traditional options for treating ischemic steal syndrome related to a functioning dialysis access graft or fistula include banding or ligation. Unfortunately, these techniques usually result in inconsistent limb salvage, loss of a functional access, or both. We report our experience with an alternative method of limb revascularization that eliminates steal while maintaining continuous dialysis access.
Patients who had critical limb ischemia and functioning arteriovenous fistulae (AVF) underwent color-flow duplex scanning, digital photoplethysmography, and arteriography. Arterial ligation distal to the AVF origin eliminated the steal physiologic mechanism while arterial bypass grafting from above to below the AVF revascularized the extremity (distal revascularization-interval ligation [DRIL] procedure).
From March 1994 through December 1996, 21 patients with functioning extremity AVFs presented with critical ischemia and steal syndrome. Eleven patients had chronic ischemia with rest pain, paresthesias, or ulcerations related to nine native fistulae (six brachiocephalic, two basilic vein transpositions, one radiocephalic) and two prosthetic bridge grafts (one upper arm, one lower extremity). Acute ischemia developed in 10 patients related to three native fistulae (two brachiocephalic, one radiocephalic) and seven prosthetic bridge grafts (three forearm, three lower extremity, one upper arm). All 21 patients were treated with the DRIL technique. Three of these patients required treatment for ischemia at the time of AVF construction. Nineteen of 21 bypass procedures were performed with autogenous vein, including nine brachial-brachial, three brachial-radial, two radial-radial, two brachial-ulnar, one popliteal-popliteal, one femoral-popliteal, and one femoral-peroneal. Polytetrafluoroethylene grafts were used for one external iliac-popliteal bypass graft and one axillary-brachial bypass graft. Limb salvage and maintenance of a functional fistula were achieved in 100% and 94%, respectively, at 18 months by life-table analysis.
The DRIL technique reliably restores antegrade flow to the ischemic limb, eliminates the potential pathway for the steal physiologic mechanism, and maintains continuous dialysis access in these difficult patients.
治疗与功能正常的透析通路移植物或动静脉内瘘相关的窃血综合征的传统方法包括束扎或结扎。不幸的是，这些技术通常导致肢体挽救效果不一致、功能性通路丧失，或两者皆有。我们报告一种替代的肢体血运重建方法的经验，该方法可消除窃血同时维持持续的透析通路。
患有严重肢体缺血且动静脉内瘘（AVF）功能正常的患者接受了彩色多普勒血流扫描、数字光电容积描记法和动脉造影。在AVF起源远端进行动脉结扎消除了窃血的生理机制，同时从AVF上方到下方进行动脉搭桥移植使肢体血运重建（远端血运重建-节段性结扎[DRIL]手术）。
从1994年3月至1996年12月，21例肢体AVF功能正常的患者出现严重缺血和窃血综合征。11例患者有慢性缺血，伴有静息痛、感觉异常或溃疡，与9个自体动静脉内瘘（6个肱头型、2个贵要静脉转位、1个桡头型）和2个人工血管搭桥移植物（1个上臂、1个下肢）相关。10例患者发生急性缺血，与3个自体动静脉内瘘（2个肱头型、1个桡头型）和7个人工血管搭桥移植物（3个前臂、3个下肢、1个上臂）相关。所有21例患者均采用DRIL技术治疗。其中3例患者在AVF构建时需要治疗缺血。21例搭桥手术中有19例采用自体静脉，包括9例肱动脉-肱动脉、3例肱动脉-桡动脉、2例桡动脉-桡动脉、2例肱动脉-尺动脉、1例腘动脉-腘动脉、1例股动脉-腘动脉和1例股动脉-腓动脉。聚四氟乙烯移植物用于1例髂外动脉-腘动脉搭桥移植和1例腋动脉-肱动脉搭桥移植。通过寿命表分析，18个月时肢体挽救率和功能性内瘘维持率分别达到100%和94%。
DRIL技术可靠地恢复了缺血肢体的顺行血流，消除了窃血生理机制的潜在途径，并在这些困难患者中维持了持续的透析通路。
