Lumsden A B, MacDonald M J, Kikeri D, Cotsonis G A, Harker L A, Martin L G
Department of Surgery, Rollins School of Public Health Emory University School of Medicine, Atlanta, Georgia, USA.
Ann Vasc Surg. 1998 Mar;12(2):138-42. doi: 10.1007/s100169900130.
Poor patency of arteriovenous ePTFE grafts remains a major clinical problem. Prophylactic balloon angioplasty of stenoses has been claimed to 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 ultrasound and those with a perigraft stenosis of >50% then underwent angiography. Those patients confirmed to have a stenosis >50% within the graft, were randomized to prophylactic percutaneous transluminal angioplasty (PTA) versus no intervention (observation). Patients were followed 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 duplex screening of the entire ePTFE dialysis group; professional and technical fees for angiography and angioplasty; follow-up duplex scanning; repeat angioplasty; and costs of lytic therapy for an intraprocedure lysis. In the treatment and observation group the 6-month patencies were 69% +/- 7% and 70% +/- 7%, respectively. Twelve-month patencies for the treatment and observation groups were 51% +/- 6% and 47% +/- 4%. There was no significant difference between these two groups (p = 0.97), with an 80% confidence limit for detection of a difference >20%. Cost for duplex screening of all patients in the dialysis unit with ePTFE grafts was $40,440 (@ $337 each x 120 patients). Total charges for initial 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 were $83,682 (professional fee $1733 + $229; technical fee + $820; equipment charges x 32 x 0.94). One patient required urokinase therapy for an occlusion following PTA. The overall charge for treating the 32 patients in the treatment arm of this study was $440,834, there was net improvement in patency. A policy of generic graft surveillance and prophylactic is expensive and does not lead to improved patency. Until an effective intervention is defined by prospective randomized trial, surveillance duplex scanning cannot be justified.
动静脉ePTFE移植物通畅性差仍然是一个主要的临床问题。有人声称对狭窄进行预防性球囊血管成形术可延长移植物通畅时间，并已广泛应用于临床实践。在本论文中，我们报告了实施这样一个项目的成本，该项目包括对ePTFE移植物进行监测以及对直径狭窄>50%的ePTFE移植物狭窄进行预防性血管成形术。单个透析单元中所有使用ePTFE搭桥移植物的患者均接受双功超声监测，那些移植物周围狭窄>50%的患者随后接受血管造影。那些被证实移植物内狭窄>50%的患者被随机分为预防性经皮腔内血管成形术（PTA）组和不干预（观察）组。每3个月对患者进行超声随访，治疗组中出现复发性狭窄（>50%）的患者接受重复PTA。观察终点为血栓形成。相关费用被认为包括：对整个ePTFE透析组进行的首次双功超声筛查；血管造影和血管成形术的专业及技术费用；随访双功超声扫描；重复血管成形术；以及术中溶栓的溶栓治疗费用。治疗组和观察组6个月时的通畅率分别为69%±7%和70%±7%。治疗组和观察组12个月时的通畅率分别为51%±6%和47%±4%。两组之间无显著差异（p = 0.97），检测差异>20%的置信限为80%。对透析单元中所有使用ePTFE移植物的患者进行双功超声筛查的费用为40440美元（@337美元/例×120例患者）。首次血管造影的总费用为178美元。血管成形术费用为143040美元。治疗组随访双功超声扫描的费用为32352美元。复发性狭窄患者重复血管造影的费用为83682美元（专业费用1733美元 + 229美元；技术费用 + 820美元；设备费用×32例×0.94）。1例患者在PTA后因闭塞需要尿激酶治疗。本研究治疗组32例患者的总治疗费用为440834美元，通畅率有净改善。一般性移植物监测和预防性治疗的政策成本高昂且不能改善通畅率。在通过前瞻性随机试验确定有效干预措施之前，双功超声监测无法得到合理的证明。
