Distal revascularization-interval ligation for maintenance of dialysis access and restoration of distal perfusion in ischemic steal syndrome

Ischemic steal syndrome after hemodialysis access challenges the clinician to reconcile the dichotomy of maintenance of access patency and restoration of distal limb perfusion. Results from traditional procedures directed toward increasing the resistance in the fistula (eg, banding, lengthening) have yielded unreliable results and frequently eventuate in fistula thrombosis. The recently described technique of distal revascularization, interval ligation (DRIL) provides a more physiological approach. Based on several recent series, application of the technique has provided excellent resolution of ischemic symptoms and superior preservation of fistula patency.