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Home > Vascular Annual Meeting > ascher_duplex_guided

Duplex-guided Balloon Angioplasty of Failing or Non-maturing Arterio-venous Access (A-V): A New Office-Based Procedure

Enrico Ascher, Natalie Marks, Anil Hingorani, Alexander Shiferson, Alessandra Puggioni.
Maimonides Medical Center, Brooklyn, N.Y.

OBJECTIVES: Unquestionably, federal government has created financial incentives for vascular interventionists to perform procedures in their offices rather than in 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 duplex scanning use as sole imaging technique. Herein we report on first 15 office-based duplex-guided balloon angioplasty cases of failing or non-maturing A-V access.

METHODS: Fifteen patients (8 males; 7 females; mean age 66.8±10.1) with chronic renal insufficiency and failing (3) or non-maturing (12) autologous arterio-venous (AV) fistulas underwent office-based duplex-guided balloon angioplasties. Indications for all procedures were severe stenoses (>70%) as measured by color duplex and confirmed by peak systolic velocity (PSV)step-up. Preoperative duplex-derived mean volumes flows(VF) 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 only.
Revenue for hospital-based and office-based procedures was compared.

RESULTS: All procedures were successfully completed without fluoroscopy and contrast material, local or systemic complications. Comparison of preoperative mean FV (243±186 ml/min) and postoperative mean VF (768±274 ml/min) demonstrated statistically significant increase with p<0.01. Preoperative mean PSV 525±69cm/sec decreased to postoperative mean PSV174±46 cm/sec (p<0.0001). Average hospital-based professional fee is currently $450; average office-based global fee is $2654. After deduction of material and personnel costs ($730/case) net profit of office-based procedure is $1924, which is 4.28 times higher.

CONCLUSIONS: This early experience suggests that office-based endovascular repair of A-V access under duplex-guidance is feasible and safe. The superficial location of A-V access facilitates duplex visualization. This proposed approach averts contrast material use and radiation exposure. Lastly, it is financially more rewarding than hospital-based procedures

AUTHOR DISCLOSURES: E. Ascher, None; N. Marks, None; A. Hingorani, None; A. Shiferson, None; A. Puggioni, None.