Gerald A. Beathard, MD, PhD, Allen R. Nissenson, MD,  Salim Mujais, MD and Physician Operators RMS Lifeline

Hemodialysis vascular access stenosis is common and frequently leads to access thrombosis. Increasingly, interventional endovascular procedures are being performed in dedicated outpatient vascular access laboratories. We have had the opportunity to evaluate such procedures over a 15-month period from a group of six dedicated vascular access centers with a centralized information system.

1,796 angioplasties were performed. Of those, 73 % were performed in synthetic grafts and 27% performed in native arteriovenous fistulae. The demographics were similar to the USRDS reported profile with a mean age of 62 years; 53% male and 47% female; 65% black, 32% white and 3% other; and 52% of the patients had diabetes mellitus.

Major indications for the angioplasty included flow restriction (27%); increased venous pressure (25%); decreased dialysis adequacy (14%); inadequate flow to the dialysis machine (7%); swollen extremity (4%); prolonged bleeding post-dialysis (3%); and inability to cannulate (3%). The location of the most common lesion was at the venous anastamosis (29%), then the venous outflow (26%), with only 5% at the arterial anastamosis. The typical patient had 1.14 lesions that required angioplasty.

The procedures were successful in 97% of the cases (K-DOQI definition- stenosis-30% post-angioplasty. Procedural success was also demonstrated by improvement in stenosis percentage from 74% (SD=15) pre-angioplasty to 19% (SD=16) post-angioplasty. 

The complication rate (using SCVIR definitions) was 0.3% major and 2% minor. 68% of the complications were a small hematoma, not affecting flow. Patient satisfaction results were good, with 88% of the respondents rating their procedural experience as very good or excellent. Compared to the average reimbursement, there were significant cost savings as well. 

Angioplasty of the hemodialysis vascular access can be performed safely and effectively in an outpatient vascular access center. The excellent outcomes coupled with high patient satisfaction and lower cost makes this setting an ideal one for such procedures.


Disclosure:
All of the authors are either employees or consultants of Baxter Healthcare. RMS Lifeline is an affiliate of Baxter Healthcare.