Office-based duplex guided hemodialysis access angioplasty safe: Study

Duplex guided dialysis access angioplasty can be performed safely and effectively in the office setting according to a new study presented today at the 64th Vascular Annual Meeting presented by the Society for Vascular Surgery®. According to researchers, ultrasound offers the advantage of treating the patient without ionizing radiation and sedation or iodinated contrast. This procedure also allows the physician to directly measure the diameter of treated vessels which facilitates the accurate sizing of balloons and stents, and to assess of the hemodynamic effects of intervention.

"Ultrasound guided intervention for hemodialysis access stenosis was first reported in 2000 and there have been several published favorable reports of duplex-guided hemodialysis access intervention done in an office setting with good results in both failing and non-maturing accesses," said David Fox, MD, FACS, a vascular surgeon at Lenox Hill Hospital in New York City.

From January 2008 through June 2009, a total of 223 office-based duplex guided hemodialysis access angioplasty procedures were performed in 125 patients by one vascular surgeon. Two hundred and eight of the treated accesses were fistula; maturation angioplasty was performed in 115 cases; and maintenance angioplasty was done in 108 cases.

"The most common indication for intervention was for maturation failure which had occurred in 104 cases," said Dr. Fox. "Other indications included pulsatility in 29, low access flow in 28, decreased flow in 23 and infiltration in 13. Procedures were performed in the office using a combination of topical and local anesthesia and volume flow was recorded prior to introducer insertion (baseline) and post intervention. In addition, stents were placed in five cases."

Researchers added that the technical advantages of office-based duplex guided hemodialysis access angioplasty include the ability to directly visualize puncture sites, stenoses, thrombus, spasm, and extravascular flow in real time. In this study, technical success was achieved in 219 cases (98.2 percent). Complications occurred in 19 cases (8.5 percent) which included two introducer site hematomas, four introducer site pseudoaneurysms, eight thrombus developments, three angioplasty site ruptures and 2 angioplasty site pseudoaneurysms.

Dr. Fox said that with the ability to measure diameter, flow velocity and volume flow also provided the opportunity to objectively and quantitatively assess the need for and the results of intervention. In this study, for all interventions combined, the average baseline volume flow was 447 ml/min and the average final volume flow was 820 ml/min. The volume flow increased by an average of 83.6 percent post intervention.

Immature fistulas had an average baseline volume flow of 271 ml/min and average final volume flow for them was 522 ml/min. The volume flow increased by an average of 93 percent after maturation angioplasty. Dysfunctional fistulae and grafts had an average baseline volume flow of 616 ml/min. Average final volume flow was 1,143 ml/min. The volume flow increased by 85.4 percent after maintenance angioplasty.

"Of course further advantages include a strong patient and physician preference for the convenience and efficiency of the office environment as compared to the hospital, and in this setting there are also potential financial advantages for the practitioner," added Dr. Fox.