Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome)
CPT4 code
Name of the Procedure:
Distal Revascularization and Interval Ligation (DRIL)
Summary
Distal revascularization and interval ligation (DRIL) is a surgical procedure aimed at restoring proper blood flow to the hand in patients who have developed steal syndrome as a complication of upper extremity hemodialysis access. Steal syndrome occurs when the hemodialysis access diverts too much blood away from the hand, causing pain and tissue damage.
Purpose
The purpose of the DRIL procedure is to alleviate symptoms of steal syndrome, such as pain and poor hand function, by rerouting blood flow. The goals are to restore adequate blood supply to the hand, preserve the functionality of the hemodialysis access, and prevent tissue damage or necrosis.
Indications
- Symptoms of steal syndrome, including hand pain, numbness, and weakness.
- Evidence of compromised blood flow to the hand as confirmed by diagnostic tests.
- Patients with arteriovenous fistula (AVF) or graft for hemodialysis access who are experiencing ischemic symptoms.
Preparation
- Patients may be instructed to fast for a certain period before the procedure.
- Medications may need to be adjusted, especially blood thinners.
- Pre-procedure diagnostic tests like Doppler ultrasound or angiography to assess blood flow.
- Comprehensive review of medical history and physical examination.
Procedure Description
- The patient is administered anesthesia (typically regional or general anesthesia).
- An incision is made near the site of the existing hemodialysis access.
- A segment of a healthy artery (often proximal to the site) is rerouted to improve blood flow to the hand.
- The artery from which the rerouted segment was taken is ligated (tied off) to prevent excess blood flow through the hemodialysis access.
- The surgical site is closed with sutures.
Tools and equipment used include surgical instruments, sutures, ultrasound or angiography imaging, and vascular clamps.
Duration
The procedure typically takes 2 to 4 hours.
Setting
The procedure is typically performed in a hospital setting, specifically in an operating room.
Personnel
- Vascular Surgeon
- Surgical Nurses
- Anesthesiologist
- Surgical Technicians
Risks and Complications
- Bleeding
- Infection
- Blood clots
- Nerve injury
- Recurrence of steal syndrome
- Complications related to anesthesia
Benefits
- Relief from pain and other symptoms of steal syndrome.
- Improved hand function and blood flow.
- Preservation of hemodialysis access.
- Benefits are often realized immediately or within days after the procedure.
Recovery
- Post-procedure monitoring in the hospital for a few hours to a couple of days.
- Instructions for wound care and pain management.
- Avoid heavy lifting and strenuous activities for several weeks.
- Follow-up appointments to monitor healing and blood flow.
Alternatives
- Conservative management with medications and hand exercises.
- Banding of the access point to reduce blood diversion.
- Revision of the existing access.
- Each alternative has its own benefits and limitations compared to DRIL, and the best option depends on individual patient factors.
Patient Experience
- During the procedure, patients will not feel pain due to anesthesia.
- Post-surgery, patients may experience pain and swelling at the incision site.
- Pain management may include prescription pain medications and over-the-counter analgesics.
- The patient may feel fatigued and will need assistance with daily activities during the initial recovery period.