{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T14:35:11Z","timestamp":1793284511672,"version":"4.5.0"},"reference-count":21,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","license":[{"start":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T00:00:00Z","timestamp":1781568000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["Kidney360"],"published-print":{"date-parts":[[2026,9]]},"abstract":"\n Key Points<\/jats:title>\n \n \n \n Surgical treatment of dialysis access\u2013associated steal syndrome achieves high symptom resolution rates, approaching 90% across observational studies.<\/jats:p>\n <\/jats:list-item>\n \n No significant differences were detected between distal revascularization with interval ligation and proximalization of the arterial inflow in symptom relief, complications, or primary patency.<\/jats:p>\n <\/jats:list-item>\n \n Current evidence supports an individualized, anatomy-driven approach rather than a single gold standard.<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>\n \n Background<\/jats:title>\n Distal revascularization with interval ligation (DRIL) is widely regarded as the gold standard for dialysis access\u2013associated steal syndrome, yet high-level comparative evidence remains scarce. We performed a systematic review and meta-analysis to evaluate whether DRIL truly outperforms alternative reconstructive strategies, particularly proximalization of the arterial inflow (PAI).<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n A Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u2011compliant systematic search identified observational studies reporting outcomes after DRIL, PAI, or revision using distal inflow for dialysis access\u2013associated steal syndrome. The review protocol was prospectively registered in the International Prospective Register of Systematic Reviews (CRD420261329250) before data extraction and study selection. The primary end point was symptom resolution. Secondary outcomes included primary patency and postoperative complications. Subgroup analyses and meta-regression were performed to explore technique-related differences and heterogeneity.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Eight studies were included. Overall symptom resolution reached 92% (95% confidence interval, 87% to 96%), with moderate heterogeneity (I\n 2<\/jats:sup>\n =58%). DRIL achieved a pooled resolution rate of 91%, while PAI demonstrated 93%, with no significant between-technique difference (\n P<\/jats:italic>\n = 0.62). No statistically significant difference in complication rates was detected between DRIL and PAI (\n P<\/jats:italic>\n = 0.56). No statistically significant difference in primary patency was detected between techniques (\n P<\/jats:italic>\n = 0.34). Meta-regression did not identify publication year or study size as significant moderators. Influence diagnostics confirmed robustness of pooled estimates.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n The available observational evidence\u2014derived exclusively from small retrospective cohorts predominantly at serious risk of bias\u2014did not demonstrate a statistically significant difference between DRIL and PAI in symptom resolution, complications, or primary patency. These results should not be interpreted as equivalence or as justification for abandoning DRIL as a cornerstone technique. Rather, they reflect the limitations of the current evidence base. In the absence of randomized data, an individualized, anatomy-driven approach is recommended, and prospective comparative studies are urgently needed.<\/jats:p>\n <\/jats:sec>","DOI":"10.34067\/kid.0000001252","type":"journal-article","created":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T18:03:43Z","timestamp":1781633023000},"page":"2087-2101","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Is Distal Revascularization with Interval Ligation Still the Gold Standard?"],"prefix":"10.34067","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8239-2498","authenticated-orcid":false,"given":"Maria Lourdes","family":"Del R\u00edo-Sol\u00e1","sequence":"first","affiliation":[{"name":"Department of Surgery, University of Valladolid, Valladolid, Spain"},{"name":"Department of Vascular Surgery, University Clinical Hospital of Valladolid, Valladolid, Spain"},{"name":"Department of Health Sciences, Universidad Europea Miguel de Cervantes, Valladolid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandra","family":"P\u00e9rez-Fern\u00e1ndez","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, University Clinical Hospital of Valladolid, Valladolid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marina","family":"Jimenez-Caja","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, University Clinical Hospital of Valladolid, Valladolid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clara","family":"De la Torre-Casaseca","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, University Clinical Hospital of Valladolid, Valladolid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sergio","family":"Asensio-Rodriguez","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, University Clinical Hospital of Valladolid, Valladolid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,6,16]]},"reference":[{"issue":"3","key":"B1-20261029","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1177\/112972980800900301","article-title":"Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies","volume":"9","author":"Malik","year":"2008","journal-title":"J Vasc Access."},{"issue":"1","key":"B2-20261029","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ejvs.2003.10.007","article-title":"Upper extremity ischemia and hemodialysis vascular access","volume":"27","author":"Tordoir","year":"2004","journal-title":"Eur J Vasc Endovasc Surg."},{"issue":"3","key":"B3-20261029","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1177\/153857440303700304","article-title":"Prediction of arteriovenous access steal syndrome utilizing digital pressure measurements","volume":"37","author":"Papasavas","year":"2003","journal-title":"Vasc Endovascular Surg."},{"issue":"3","key":"B4-20261029","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1016\/j.jus.2010.09.003","article-title":"Ischemic steal syndrome in a hemodialysis patient: the roles of Doppler ultrasonography and dynamic Doppler studies in diagnosis and treatment selection","volume":"13","author":"Mascia","year":"2010","journal-title":"J Ultrasound."},{"issue":"3","key":"B5-20261029","doi-asserted-by":"crossref","first-page":"754","DOI":"10.1016\/j.jvs.2014.10.038","article-title":"Management and outcomes of dialysis access-associated steal syndrome","volume":"61","author":"Leake","year":"2015","journal-title":"J Vasc Surg."},{"issue":"4","key":"B6-20261029","doi-asserted-by":"crossref","first-page":"926","DOI":"10.1016\/j.jvs.2008.05.028","article-title":"Midterm outcome after the distal revascularization and interval ligation (DRIL) procedure","volume":"48","author":"Huber","year":"2008","journal-title":"J Vasc Surg."},{"issue":"2","key":"B7-20261029","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1177\/112972981001100211","article-title":"Proximalization of the arterial inflow (PAI) in patients with dialysis access-induced ischemic syndrome: first report on long-term clinical results","volume":"11","author":"Thermann","year":"2010","journal-title":"J Vasc Access."},{"issue":"6","key":"B8-20261029","doi-asserted-by":"crossref","first-page":"1216","DOI":"10.1016\/j.jvs.2006.01.025","article-title":"Proximalization of the arterial inflow: a new technique to treat access-related ischemia","volume":"43","author":"Zanow","year":"2006","journal-title":"J Vasc Surg."},{"key":"R9-20261029","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1067\/mva.2002.125025","article-title":"Distal revascularization\u2013interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access","volume":"36","author":"Knox","year":"2002","journal-title":"J Vasc Surg"},{"issue":"1","key":"B14-20261029","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1016\/j.jvs.2010.10.134","article-title":"Treatment strategies of arterial steal after arteriovenous access","volume":"54","author":"Gupta","year":"2011","journal-title":"J Vasc Surg."},{"key":"R11-20261029","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.avsg.2021.01.102","article-title":"Distal revascularization and interval ligation for the management of dialysis access steal syndrome","volume":"74","author":"Alie-Cusson","year":"2021","journal-title":"Ann Vasc Surg"},{"key":"R12-20261029","doi-asserted-by":"crossref","first-page":"1090","DOI":"10.1016\/j.jvs.2024.05.045","article-title":"Proximalization of arterial inflow for treatment of hemodialysis access-induced distal ischemia","volume":"80","author":"Bachmann","year":"2024","journal-title":"J Vasc Surg"},{"issue":"4","key":"B17-20261029","doi-asserted-by":"crossref","first-page":"473","DOI":"10.3400\/avd.ra.18-00051","article-title":"Revision using distal inflow for the treatment of dialysis access steal syndrome: a systematic review","volume":"11","author":"Kordzadeh","year":"2018","journal-title":"Ann Vasc Dis."},{"issue":"4","key":"B16-20261029","doi-asserted-by":"crossref","first-page":"1364","DOI":"10.1016\/j.jvs.2019.02.060","article-title":"A systematic review of distal revascularization and interval ligation for the treatment of vascular access-induced ischemia","volume":"70","author":"Kordzadeh","year":"2019","journal-title":"J Vasc Surg."},{"issue":"3","key":"B9-20261029","first-page":"141","article-title":"Treatment options for dialysis access steal syndrome","volume":"19","author":"Papadoulas","year":"2022","journal-title":"Kardiochir Torakochirurgia Pol."},{"issue":"4","key":"B10-20261029","first-page":"375","article-title":"Distal ischemia induced by vascular access for hemodialysis - a case report","volume":"16","author":"Stolic","year":"2012","journal-title":"Hippokratia."},{"issue":"12","key":"B13-20261029","doi-asserted-by":"crossref","first-page":"1592","DOI":"10.2215\/CJN.0000000000000310","article-title":"Vascular access-related distal ischemia requiring intervention: frequency, risk factors, and consequences","volume":"18","author":"Allon","year":"2023","journal-title":"Clin J Am Soc Nephrol."},{"issue":"4 suppl 2","key":"B18-20261029","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1053\/j.ajkd.2019.12.001","article-title":"KDOQI clinical practice guideline for vascular access: 2019 update","volume":"75","author":"Lok","year":"2020","journal-title":"Am J Kidney Dis."},{"issue":"3","key":"B11-20261029","doi-asserted-by":"crossref","first-page":"603","DOI":"10.1067\/mva.2002.122025","article-title":"Recommended standards for reports dealing with arteriovenous hemodialysis accesses","volume":"35","author":"Sidawy","year":"2002","journal-title":"J Vasc Surg."},{"issue":"4","key":"B12-20261029","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1038\/ki.2009.461","article-title":"The MILLER banding procedure for dialysis-associated steal syndrome","volume":"77","author":"Miller","year":"2010","journal-title":"Kidney Int"},{"issue":"6","key":"B15-20261029","doi-asserted-by":"crossref","first-page":"1273","DOI":"10.1016\/j.jvs.2006.08.010","article-title":"Flow reduction in high-flow arteriovenous access using intraoperative flow monitoring","volume":"44","author":"Zanow","year":"2006","journal-title":"J Vasc Surg."}],"container-title":["Kidney360"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.34067\/KID.0000001252","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T14:00:51Z","timestamp":1793282451000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.34067\/KID.0000001252"}},"subtitle":["A Comparative Meta-Analysis and Meta-Regression of Surgical Treatments of Dialysis Access\u2013Associated Steal Syndrome"],"short-title":[],"issued":{"date-parts":[[2026,6,16]]},"references-count":21,"journal-issue":{"issue":"9","published-print":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.34067\/kid.0000001252","relation":{},"ISSN":["2641-7650","2641-7650"],"issn-type":[{"value":"2641-7650","type":"electronic"},{"value":"2641-7650","type":"print"}],"subject":[],"published":{"date-parts":[[2026,6,16]]},"assertion":[{"value":"2026-03-09","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-06-06","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}