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Revision Using Distal Inflow: A Safe and Effective Treatment for Ischemic Steal Syndrome After Access Creation
Thomas M Loh, Matthew E Bennett, Mark G Davies, Eric K Peden
Houston Methodist, Houston, TX

BACKGROUND: Ischemic steal syndrome (ISS) is a dreaded complication following hemodialysis access creation. Its management is complex and varied with a majority requiring surgical revision for correction of symptoms. Revision Using Distal Inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience, of RUDI for the treatment of ISS and pathologic high flow (HF).
METHODS: We retrospectively review consecutive patients who underwent RUDI for ISS from April, 2010 to March, 2014. Data collection included demographics, past medical histories, subsequent procedures, volume flows, access usage, limb salvage and patient survival.
RESULTS: We performed 32 RUDI in 31 patients (18 women, 13 men). Indications for surgery were pathologic high flow in 15 and ISS in 21. 16% had prior plication for ISS or HF. 71% of patients had a history of diabetes. 52% had a history of atherosclerotic disease. Time to intervention from creation was 40 months (range, 6-88). Accesses included 1 upper arm graft and 30 brachial artery based fistulas. Outflow included 26 cephalic veins and 4 basilic veins. Distalization targets were 20 radial arteries, 9 ulnar arteries and 3 distal brachial arteries. Mean flow reduction was 994cc/min. Primary assisted patency at 1 year was 73%. Secondary patency at 1 year was 88%. One patient had their RUDI revised from a distal brachial to radial inflow. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 81% and partial in 19%.
CONCLUSIONS: RUDI is an effective and lasting treatment of ISS and HF comparable to reported experiences with DRIL, PAI and plication. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.

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