Regarding 'prediction of graft patency and mortality after distal revascularization and interval ligation for hemodialysis access-related hand ischemia' and 'using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation'

摘要

I read with great interest the recent studies by Scali et al and Amaiq and Katz. Their results, from large numbers of patients, supported the efficacy of the distal revascularization and interval ligation (DRIL) procedure to treat access-related ischemia (ABJ). In particular, they demonstrated the safety of DRIL, as indicated by impressive patency as well as only moderate symptoms in case of bypass thrombosis. These results lend further support to DRIL as the method of choice for ARI treatment.However, in a significant number of our patients, we have noted forearm arteries with severe occlusive disease, which may imply a less favorable patency of bypasses; moreover, there are unreported incidences and reports of fatal outcomes after DRIL. We will therefore continue to apply our concept of differentiated treatment of ARI, which includes banding with flow measurement for high-flow accesses and proximalization of arterial inflow (PAI) for moderate-flow and low-flow accesses. Despite a larger share of patients with tissue loss, we observed complete symptom resolution and access patency by using less invasive banding or PAI. Potential negative effects from the use of prosthesis (a 4- to 7-mm stepped graft is now most widely used) were not seen, especially if the PAI graft was used only as a feeder and not for puncture and the fistula vein was matured before revision. In selected patients, we used saphenous or cephalic veins, similar to the preventive PAI procedure described by Jennings et al.