USG GUIDED AV FISTULA BALLOON ANGIOPLASTY FOR OPTIMIZING COST-EFFICIENCY AND ACCESSIBILITY: A COMPREHENSIVE ANALYSIS OF TECHNICAL ASPECTS AND OUTCOME

Introduction:

Arteriovenous (AV) fistulas are crucial for hemodialysis patients but often face complications such as stenosis. Traditional intervention for this rely on fluoroscopy, which presents accessibility challenges due to cost and infrastructure limitations. This study investigates the feasibility and outcomes of using ultrasound guidance (USG) for AV fistula balloon angioplasty as a cost-effective and accessible alternative.

Methods:

This was an single group interventional study conducted in a tertiary care teaching hospital in South India, from June 2023 to February 2024. Study included patients over 18 years with AV fistula stenosis confirmed by ultrasound doppler imaging. Exclusion criteria were central vein stenosis, active infections, and AV fistula failure during critical illness. Participants underwent USG-guided balloon angioplasty, with follow-up for 6 months to assess immediate success, re-intervention-free survival rates, and complications.

Results:

Fifty-four patients underwent USG-guided balloon angioplasty. The mean age was 58.4 ± 11.5 years, with 77% male participants. The mean dialysis vintage was 2.4 ± 1.3 years. Fistula types included radial-cephalic (51.9%), brachial-cephalic (38.9%), and brachial-basilic (9.3%). Stenosis locations were juxta-anastomotic (53.7%), mid-venous (20.3%), outflow region (14.8%), and multiple areas (11.1%).

A 5 Fr vascular sheath was used in 41 patients and a 6Fr sheath in 13 patients. The sheath was positioned depending on stenosis location in the venous segment of AV fistula as anterograde or retrograde. A 20G IV cannula and 0.035-inch guide wire were employed for sheath insertion. 0.014-inch wire was introduced through the sheath for negotiating the stenosis, which was successful in 49 patients. Non compliant coronary balloon was passed over the wire and inflated to 8-10 ATM. The median diameter of the balloon used was 4mm (IQR 3-5 mm). The median number of dilatations done was 3 (IQR 2-3). See Figure 1-5.

Significant bleeding requiring compression for over 30 minutes was noted in 6 of 13 patients with 6 Fr sheaths and 10 of 41 with 5 Fr sheaths (P = 0.288). Two patients experienced partial dissection following balloon dilatation which was managed by balloon re inflation and tamponade. Immediate success was achieved in 51 of 54 patients, with 44 patients achieving a blood flow rate ≥250 ml/min and remaining 7 patients achieved a flow between 200-250 ml/min. All patients had online Kt/V >1 during the hemodialysis session post procedure. Normalization of high venous pressure was observed in 8 patients with outflow stenosis.

During a 6-month follow-up, 1 patient expired, 5 developed restenosis (within 3-5 months), and 1 experienced acute thrombosis successfully thrombolysed. Re-intervention-free survival at 6 months was 88.2%.

Conclusions:

USG-guided AV fistula balloon angioplasty proves to be a viable, cost-effective alternative to fluoroscopic guidance, especially in resource-limited settings. The technique successfully restored function in 94.4% of patients with manageable complications. This approach can enhance accessibility to critical interventions and reduce reliance on expensive infrastructure. Future studies with larger samples and extended follow-up are needed to further validate these findings and assess long-term outcomes.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.