LAUSR

OBJECTIVES Distal revascularization and interval ligation (DRIL) is an effective approach to management of hemodialysis access-related ischemia that offers both symptom relief and access salvage. Greater saphenous vein (GSV) is the most commonly utilized conduit. However, the use of ipsilateral arm vein allows for performance of the operation under regional anesthesia and may have lower harvest site morbidity than GSV. We sought to determine the suitability of DRIL utilizing arm vein as compared to GSV conduit. METHODS All patients who underwent DRIL between 2008 and 2019 were retrospectively identified in the electronic medical record. Characteristics and outcomes of those with arm vein versus GSV conduit were compared using Wilcoxon log-rank and chi-square tests. Access patency was examined using Kaplan-Meier methods, with censoring at loss to follow-up or death. RESULTS 66 patients who underwent DRIL for hand ischemia were included in the study. Arm vein conduit was utilized in 40 patients (median age 65 years, 25% male) and GSV conduit in 26 patients (median age 58 years, 19% male). There were no significant differences in comorbid conditions between the two groups, with the exception of diabetes mellitus (DM) (78% arm vein vs 50% GSV, P=0.02). There was no difference in ischemia stage at presentation between the groups, with most patients presenting with stage 3 ischemia. There was no difference in patency of hemodialysis access following DRIL by arm vein vs. GSV conduit (P=0.96). At 12 and 24 months after DRIL 86.9% (95% CI 68.3%-94.9%) and 82.0% (95% CI 61.3%-92.3%) of patients with arm vein conduit maintained access patency compared to 93.8% (95% CI 63.2%-99.1%) and 76.9% (95% CI 43.0%-92.2%) of those with GSV conduit. All but one patient had symptom resolution. Wound complications were significantly greater in the GSV as compared to the arm vein conduit group (46% vs 11%, P=0.003). DRIL bypass remained patent in all but one patient in each group with median follow-up of 18 months in the arm vein conduit group (range 1-112 months) and 15 months in the GSV conduit group (range 0.25-105 months). CONCLUSION DRIL procedures utilizing arm vein have advantages over those performed with saphenous vein. In our series, symptom resolution and access salvage were similar, but there were distinctly fewer wound complications. Additionally, utilization of arm vein conduit avoids the need for use of general anesthetic. If ipsilateral arm vein is available it should be the conduit of choice when performing DRIL.