SS13 - Proximalization of Arterial Inflow Should Replace DRIL for Treatment of Steal Syndrome: Largest in Literature Case Series

Objectives: Dialysis associated steal syndrome (DASS) is a commonly encountered complication of hemodialysis (HD) access. Distal revascularization interval ligation (DRIL) is the most consistently documented treatment for DASS in the literature. Proximalization of arterial inflow (PAI) is an alternative promising technique that, unlike DRIL, preserves the native arterial inflow. The purpose of this study is to report our experience with PAI on a series of 64 patients.

Methods: This is a single-center, retrospective cohort study of patients who had undergone PAI for DASS from 2017 to 2023. A 4x7 tapered PTFE graft was used to connect HD access inflow to the axillary artery. The primary outcome of the study is resolution of DASS (complete, partial, or no resolution). Secondary outcomes include patency (primary and secondary) and 30-day complications following PAI.

Results: Of the 74 patients identified to have had PAI between May 2017 to August 2023, 3 did not have PAI for DASS, and 7 were lost to follow-up. In total, 64 patients were included, with an average age of 65 years (SD 15), 59.4% (38/64) female, and 37.5% (24/64) African American. The study population was notable for numerous comorbid conditions, including 95.3% (61/64) HTN, 50% (32/64) CAD, 79.7% (51/64) diabetes, and 43.8% (28/64) smoking history. Following PAI intervention for DASS, 55/64 (85.9%) patients experienced complete resolution of ischemic symptoms, 5/64 (7.8%) patients had partial resolution, 2/64 (3.1%) patients had no resolution, and 2/64 (3.1%) patients had unknown resolution. Primary patency at 1, 12, and 24 months was 94%, 81%, and 71%, respectively. Secondary patency at 1, 12, and 24 months was 97%, 87%, and 84%, respectively. Patency is illustrated in a Kaplan-Meier curve in Figure 1. The 30-day complication rate was 10.9% (7/64), with 5/64 (7.8%) thromboses, 1/64 (1.6%) thrombosis and infection, and 1/64 (1.6%) upper extremity swelling secondary to central venous stenosis (resolved with angioplasty of central venous system). Failure rate due to thrombosis at 12 and 24 months was 14% (9/64) and 15.6% (10/64), respectively.

Conclusions: Our study, the largest case series of PAI to-date, demonstrates that PAI is a reliable option for DASS intervention that has comparable safety and efficacy results to DRIL. However, PAI has the added benefit of maintaining the native arterial pathway. Further investigation of PAI is warranted as a promising alternative to DRIL for DASS management.