title: Cephalic arch stenosis: angioplasty to preserve a brachiocephalic fistula or new brachiobasilic fistula? A cost-effectiveness study.
abstract: BACKGROUND
  Our aim was to evaluate the cost-effectiveness of repeat angioplasty versus new brachiobasilic fistula (BBF) in patients with symptomatic cephalic arch stenosis (CAS).
  
  
  METHODS
  Patients presenting with symptomatic CAS (n = 22) underwent angioplasty. They were compared to patients undergoing BBF creation (n = 51). Primary outcomes were functional primary arteriovenous fistulae patency at 3, 6 and 12 months. Data were collected on number of interventions, alternative accesses and hospital days for access-related complications. Quality of life was assessed using Kidney Disease Quality of Life-36 scores. Decision tree, Monte Carlo simulation and sensitivity analysis permitted cost-utility analysis. Healthcare costs were derived from Department of Health figures and are presented as cost (£)/patient/year, cost/access preserved and cost/quality of life-adjusted year (QALY) for each of the treatment strategies.
  
  
  RESULTS
  Functional primary patency rates at 3, 6, 12 months were 87.5%, 81% and 43% for repeated angioplasty and 78%, 63% and 41% for BBF. The angioplasty cohort required 1.64 ± 0.23 angioplasties/patient and 0.64 ± 0.34 lines/patient. BBF required 0.36 ± 0.12 angioplasties/patient and 1.2 ± 0.2 lines/patient. Patients in the BBF cohort spent an additional 0.9 days/year in hospital due to access-related complications. Mean cost/patient/year in the angioplasty group was £5247.72/patient/year versus £3807.55/patient/year in the BBF cohort. Mean cost per access saved was £11,544.98 (angioplasty) versus £4979.10 (BBF). Average cost per QALY was £13,809.79 (angioplasty) versus £10,878.72 per QALY (BBF).
  
  
  CONCLUSIONS
  CAS poses a difficult management problem with poor outcomes from conventional angioplasty. Optimal management will depend on patient factors, local outcomes and expertise, but consideration should be given to creation of a new BBF as a cost-effective means to manage this difficult problem.
authors.affiliation: Department of Renal Surgery, Western Infirmary , Glasgow , UK .
authors.forename: Emma L
authors.initials: EL
authors.lastname: Aitken
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Jackson
authors.forename: Harris
authors.initials: H
authors.lastname: Hameed
authors.forename: Mohan
authors.initials: M
authors.lastname: Chandramohan
authors.forename: Ram
authors.initials: R
authors.lastname: Kasthuri
authors.forename: David B
authors.initials: DB
authors.lastname: Kingsmore
mesh_terms: D000800:Angioplasty, Balloon / Q000191:economics*; D001166:Arteriovenous Shunt, Surgical / Q000191:economics*; D003251:Constriction, Pathologic / Q000191:economics / Q000601:surgery; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000628:therapy; D012189:Retrospective Studies; D014652:Vascular Diseases / Q000191:economics* / Q000601:surgery
keywords: Angioplasty; arteriovenous fistula; cephalic arch stenosis; cost-utility