title: Duplex-guided balloon angioplasty of failing or nonmaturing arterio-venous fistulae for hemodialysis: a new office-based procedure.
abstract: OBJECTIVE
  Unquestionably, the federal government has created financial incentives for vascular interventionists to perform procedures in their offices rather than in a hospital setting. While office venous ablations have been widely embraced by the vascular community, those involving the arterial system have not. One important reason may be related to the cost of the fluoroscopic equipment. Herein, we report on 32 office-based duplex scan-guided balloon angioplasty cases for failing or nonmaturing arteriovenous (AV) access.
  
  
  METHODS
  Twenty-five patients (14 males; 11 females; mean age 65.1 +/- 9.11) with chronic renal insufficiency underwent 32 office-based ultrasound scan-guided balloon angioplasties of their autologous AV fistulas. Twenty-seven procedures were performed in fistulas that did not mature while the remaining five were performed in failing AV accesses. The indications for these procedures were severe stenoses (>70%) as measured by color duplex scan and confirmed by peak systolic velocity (PSV) step-up >3. Preoperative duplex scan-derived mean volume flows (VFs) and highest stenotic PSV were recorded and compared with postoperative findings. Access site puncture and cannulation with short sheath, wire, and balloon advancement and inflation were guided by duplex scan only. A comparison of revenue for hospital-based vs office-based procedures was performed.
  
  
  RESULTS
  All procedures were successfully completed without fluoroscopy and contrast material. There were no systemic complications. One patient (3%) developed an arm hematoma due to focal vein rupture which was controlled by a hand compression for 20 minutes. An additional patient (3%) had a focal intraluminal dissection not obstructing the flow. Comparison of preoperative mean VF (350 +/- 180 mL/minute) and postoperative mean VF (933 +/- 332 mL/minute) demonstrated a statistically significant increase with P < .0001. Preoperative mean PSV 582 +/- 923 cm/second decreased to postoperative 1 mean PSV 244 +/- 97 cm/second (P < .0001). After deduction of procedure-related expenses ($730/case) from the global fee, the net income from these 32 cases totaled $51,746, making the return 4.32 times higher than that of the hospital setting (potential professional fee for the same cases - $11,983).
  
  
  CONCLUSIONS
  This early experience suggests that office-based endovascular repair of AV access under duplex scan-guidance is feasible and safe. The superficial location of AV access facilitates duplex scan visualization. This proposed approach averts contrast material use and radiation exposure. Finally, it appears to be financially more lucrative than the same hospital-based procedures.
authors: Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY 11219, USA.
authors: Enrico
authors: E
authors: Ascher
authors: Anil
authors: A
authors: Hingorani
authors: Natalie
authors: N
authors: Marks
mesh_terms: D000368:Aged; D000553:Ambulatory Care / Q000191:economics; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000191:economics; D001166:Arteriovenous Shunt, Surgical; D003251:Constriction, Pathologic; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D005260:Female; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D017048:Health Care Costs; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000191:economics; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000628:therapy; D017211:Treatment Failure; D018615:Ultrasonography, Doppler, Color; D018084:Ultrasonography, Interventional; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency