Revision options for treatment of brachiocephalic fistula steal

(A) For the DRIL procedure, a bypass is created from the brachial artery at least 10 cm proximal to the anastomosis to the distal brachial or proximal radial artery. The brachial artery is then ligated just distal to the original anastomosis, being certain to preserve flow into the ulnar and radial arteries from the bypass. The distal circulation now depends on the patency of the new bypass, placing the extremity at risk if the bypass fails.
(B) For the RUDI procedure, the fistula's inflow is moved to a more distal arterial source (radial or ulnar artery) and the original fistula vein is ligated just above the anastomosis. In contrast to the DRIL procedure, the RUDI puts the fistula, rather than the extremity, at risk by preserving the native arterial circulation.
(C) For PAI, a bypass is created from the proximal brachial or axillary artery to the outflow vein distal to the original anastomosis. The original fistula outflow vein is then ligated just above the anastomosis. Similar to the RUDI procedure, PAI puts the fistula rather than the extremity at risk.