CPT® Code 36838

Distal revascularization and interval ligation (DRIL) is a surgical procedure performed to address complications arising from hemodialysis access, specifically in cases of steal syndrome. Steal syndrome occurs when the blood flow intended for the hand is diverted due to the presence of a hemodialysis access site, leading to ischemia, which is a deficiency of blood supply, and resulting in symptoms such as hand pain. The primary goal of the DRIL procedure is to restore adequate blood flow to the hand by creating a bypass around the hemodialysis access site. This is achieved by placing a bypass graft in the arm, with one end of the graft connected to the artery above the hemodialysis access site (proximal anastomosis) and the other end connected to the artery below the access site (distal anastomosis). The procedure involves making incisions in the upper and lower arms to access the brachial artery, which is the main artery supplying blood to the arm. The surgical steps include exposing the artery, creating a subcutaneous tunnel for the graft, harvesting a vein graft (often from the saphenous vein in the leg), and performing anastomoses to connect the graft to the brachial artery. Additionally, the procedure includes ligating a segment of the brachial artery to prevent retrograde blood flow into the hemodialysis access, thereby ensuring improved perfusion to the hand. The success of the procedure is confirmed by checking blood flow through the graft and evaluating distal pulses to ensure the bypass graft remains patent.