Is DRIL Still the Gold Standard?

BACKGROUND: Distal revascularization with interval ligation (DRIL) is widely regarded as the gold standard for dialysis access-associated steal syndrome (DASS), 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). METHODS: A PRISMA-compliant systematic search identified observational studies reporting outcomes after DRIL, PAI, or RUDI for DASS. The review protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420261329250) prior to data extraction and study selection. The primary endpoint 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. RESULTS: Eight studies were included. Overall symptom resolution reached 92% (95% CI 87-96%), with moderate heterogeneity (I2 = 58%). DRIL achieved a pooled resolution rate of 91%, while PAI demonstrated 93%, with no significant between-technique difference (P = 0.62). No statistically significant difference in complication rates was detected between DRIL and PAI (P = 0.56). No statistically significant difference in primary patency was detected between techniques (P = 0.34). Meta-regression did not identify publication year or study size as significant moderators. Influence diagnostics confirmed robustness of pooled estimates. CONCLUSIONS: The available observational evidence - derived exclusively from small retrospective cohorts predominantly at serious risk of bias - did not demonstrate a statistically significant difference between DRIL and PAI with respect to 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.