Some thoughts on the management of haemodialysis access-induced distal ischaemia

At CiDA 2026 in Washington, an entire session was dedicated to haemodialysis access-induced distal ischaemia (HAIDI), including a provocative debate entitled “Is DRIL dead?”

I did not attend the meeting myself, so I cannot comment on the arguments presented or the outcome of the debate. Nevertheless, the question is certainly worth discussing.

After decades of clinical experience with different surgical techniques, we still lack randomized trials directly comparing distal revascularization with interval ligation (DRIL) and proximalization of arterial inflow (PAI).

A recent systematic review and meta-analysis published in Kidney360 included eight observational studies. Resolution of ischaemic symptoms was reported in approximately 91% of patients following DRIL and 93% following PAI, without a statistically significant difference between the two procedures.

However, the included studies were relatively small, heterogeneous, and predominantly retrospective. These findings therefore do not establish equivalence between the two techniques.

What Are We Actually Treating?

In my view, the central question is not whether DRIL or PAI is the better operation.

Rather, we first need to understand which mechanism is responsible for the patient's hand ischaemia.

A patient with a high-flow AV fistula and impaired distal perfusion presents a different haemodynamic problem from a patient with normal or low access flow, significant peripheral arterial disease, or compromised arterial inflow.

This distinction is fundamental because the available surgical techniques address different pathophysiological mechanisms.

When excessive access flow contributes to distal ischaemia, flow reduction using one of several banding techniques may be appropriate.

Revision using distal inflow (RUDI) offers another option, particularly in selected high-flow configurations.

PAI and DRIL, on the other hand, are reconstructive procedures aimed at improving distal perfusion while preserving the dialysis access.

The choice therefore depends not only on access flow, but also on arterial anatomy, the severity of ischaemia, available vessels, previous interventions, and the need to maintain reliable dialysis access.

An Individualized Treatment Strategy

In my opinion, the choice of surgical procedure should always be preceded by a structured haemodynamic assessment.

This includes clinical examination, duplex ultrasound, access-flow measurement, and evaluation of possible arterial inflow disease or distal arterial pathology.

The objective is not to preserve an AV fistula at any cost, but to relieve hand ischaemia while maintaining a functional dialysis access whenever feasible.

And What About PAI?

At this point, I should probably disclose my own preference: PAI has been one of my favourite techniques for many years.

My interest in this approach is not new. Back in 2014, together with Klaus Konner and colleagues, we published a modified PAI technique using autologous veins in patients with access-related hand ischaemia.

The idea was to preserve the advantages of an autogenous AV fistula while avoiding the prosthetic graft commonly used for proximalization of arterial inflow.

In appropriately selected patients, I still consider PAI an attractive reconstructive option, particularly because it does not require interval ligation of the native artery.

Nevertheless, personal preference should never replace haemodynamic assessment. Depending on the underlying mechanism, flow reduction, RUDI, or DRIL may be the more appropriate solution.

Conclusion

The debate about whether DRIL should still be considered the gold standard is certainly interesting.

However, the more relevant question, in my view, is whether we consistently select our surgical strategy according to the actual cause of hand ischaemia.

The management of access-related hand ischaemia requires an individualized, haemodynamically guided strategy — not one standard operation for every patient.

References

1. CiDA 2026 – Controversies in Dialysis Access. Session on haemodialysis access-induced distal ischaemia (HAIDI), October 29, 2026, Washington, DC. Conference programme

2. Del Río-Solá ML et al. Is Distal Revascularization with Interval Ligation Still the Gold Standard? A Comparative Meta-Analysis and Meta-Regression of Surgical Treatments of Dialysis Access–Associated Steal Syndrome. Kidney360. 2026;7:2087–2101. DOI: 10.34067/KID.0000001252

3. Matoussevitch V et al. A Modified Approach of Proximalization of Arterial Inflow Technique for Hand Ischemia in Patients with Matured Basilic and Cephalic Veins. European Journal of Vascular and Endovascular Surgery. 2014;48(4):472–476. DOI: 10.1016/j.ejvs.2014.07.003

Dr. Vladimir Matoussevitch | VascularAccessTalk