Ab. Lumsden et al., COST EFFICACY OF DUPLEX SURVEILLANCE AND PROPHYLACTIC ANGIOPLASTY OF ARTERIOVENOUS EPTFE GRAFTS, Annals of vascular surgery, 12(2), 1998, pp. 138-142
Citations number
31
Categorie Soggetti
Surgery,"Peripheal Vascular Diseas","Cardiac & Cardiovascular System
Poor patency of arteriovenous ePTFE grafts remains a major clinical pr
oblem. Prophylactic balloon angioplasty of stenoses has been claimed t
o prolong graft patency and has been widely introduced into practice.
In this manuscript we report the cost incurred in application of such
a program involving graft surveillance and prophylactic angioplasty of
ePTFE graft stenoses >50% diameter. All patients in a single dialysis
unit with ePTFE bridge grafts were subject to a surveillance duplex u
ltrasound and those with a perigraft stenosis of >50% then underwent a
ngiography. Those patients confirmed to have a stenosis >50% within th
e graft, were randomized to prophylactic percutaneous transluminal ang
ioplasty (PTA) versus no intervention (observation). Patients were fol
lowed every 3 months with ultrasound and those in the treatment group
with recurrent stenosis (>50%) were subject to repeat PTA. The outcome
was thrombosis. Relevant charges were considered to be: initial duple
x screening of the entire ePTFE dialysis group; professional and techn
ical fees for angiography and angioplasty; follow-up duplex scanning;
repeat angioplasty; and costs of lytic therapy for an intraprocedure l
ysis. In the treatment and observation group the 6-month patencies wer
e 69% +/- 7% and 70% +/- 7%, respectively. Twelve-month patencies for
the treatment and observation groups were 51% +/- 6% and 47% +/- 4%. T
here was no significant difference between these two groups (p = 0.97)
, with an 80% confidence limit for detection of a difference >20%. Cos
t for duplex screening of all patients in the dialysis unit with ePTFE
grafts was $40,440 (@ $337 each x 120 patients). Total charges for in
itial angiography was $178. Angioplasty charges were $143,040. Cost of
the follow-up duplex ultrasound scanning in the treated group was $32
,352. Charges for repeat angiograms in those with recurrent stenoses w
ere $83,682 (professional fee $1733 + $229; technical fee + $820; equi
pment charges x 32 x 0.94). One patient required urokinase therapy for
an occlusion following PTA. The overall charge for treating the 32 pa
tients in the treatment arm of this study was $440,834, there was net
improvement in patency. A policy of generic graft surveillance and pro
phylactic is expensive and does not lead to improved patency. Until an
effective intervention is defined by prospective randomized trial, su
rveillance duplex scanning cannot be justified.