Distal Revascularization— Interval Ligation (DRIL) for the Treatment of Dialysis Access Steal Phenomenon

The incidence and prevalence of end-stage renal disease continues to grow, even as treatments improve. The vascular steal phenomenon is an infrequent but often debilitating complication of dialysis access placement, and management can be difficult. A specific technique called distal revascularization—interval ligation, or the DRIL procedure, has been used with success in managing this problem. Anatomically, the site of the steal is bypassed, and the native vessel just distal to the steal site is ligated, making duplex sonography evaluation complex. An examination algorithm is presented, with illustrative examples, to assist the sonographer in evaluating dialysis access patients when they have had the DRIL procedure. The algorithm is based on breaking the study into more easily managed components: (1) duplex sonographic evaluation of arterial inflow and runoff as well as venous outflow, (2) duplex sonographic evaluation of the bypass graft, (3) duplex sonographic evaluation of the fistula/shunt, and (4) physiologic testing of flows to the hand and digits. Based on the knowledge of the pathophysiology of steal and the configuration of the DRIL reconstruction, a complete and accurate evaluation can be performed with confidence.