Preoperative duplex examination in patients with dialysis access-related hand ischemia: indication for distal radial artery ligation.

Purpose: To demonstrate that treatment with distal radial artery ligation (DRAL), based on preoperative evaluation with duplex ultrasound, is effective for correction of hand ischemia related to distal radiocephalic arteriovenous fistula (AVF). Methods: Two patients with symptoms of hemodialysis access-induced distal ischemia (HAIDI) related to radiocephalic AVF at wrist (necrotic lesion of fingers, pain at rest and loss of sensory function) were studied with preoperative duplex examination. Color Doppler ultrasound (CDU) showed low-normal flux (700 and 500 mL/min respectively), retrograde flow in the DRA and increased digital perfusion after manual occlusion of DRA. They were both treated by ligation of the DRA. Results: Both patients had immediate improvement of ischemic symptoms. Reversed DRA flow disappeared and peripheral flow ameliorated. Postoperative AVF flow was 500 and 350 mL/min, stable at 16 and 8 months of follow-up, respectively. Conclusions: Preoperative CDU examination, simulating reversed DRA flow interruption, seems to be an effective tool to predict the success of DRAL procedure.