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25 January 2025: Clinical Research  

Cost-Effective Day Surgery for Arteriovenous Fistula Stenosis: A Viable Model for Hemodialysis Patients

Yi Zeng ORCID logo1BCE, Jing Wen ORCID logo1BCD, Shen Zhan ORCID logo1BCD, Xuyang Hao ORCID logo1BCD, Yuzhu Wang ORCID logo1AEF*, Lihong Zhang ORCID logo1AEFG

DOI: 10.12659/MSM.946128

Med Sci Monit 2025; 31:e946128

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Abstract

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BACKGROUND: For patients with end-stage renal disease, arteriovenous fistulas (AVFs) are often used for hemodialysis, but stenosis can impair their function. Traditional inpatient procedures to address AVF stenosis are effective but resource-intensive, prompting the need for alternative approaches like day surgery to optimize care and reduce costs. This study evaluated the feasibility of a day surgery model for AVF stenosis treatment in maintenance hemodialysis (MHD) patients, aiming to develop a cost-effective and high-quality care model.

MATERIAL AND METHODS: A prospective cohort study was conducted with 186 MHD patients undergoing AVF stenosis intervention between July 2022 and May, 2023. Patients were divided into a day surgery group (n=112) and a ward group (n=74). Various preoperative, intraoperative, and postoperative parameters were recorded, including AVF patency, complications, and rehospitalization rates. Follow-up assessments were conducted on postoperative days 1, 3, 7, and 30, with long-term patency evaluated at 6 and 12 months.

RESULTS: The day surgery group achieved a technical success rate of 99.11% and a complication rate of 3.57%, compared to 97.30% and 1.35% in the ward group. The day surgery group also had significantly shorter waiting times for beds, shorter hospital stays, and lower hospitalization costs (P<0.01). No significant differences were found between the groups in preoperative or postoperative parameters.

CONCLUSIONS: The day surgery model for AVF stenosis intervention in MHD patients is a viable option, showing comparable success and complication rates to inpatient surgery while significantly reducing hospital stays and costs.

Keywords: Feasibility Studies, Hemodialysis Units, Hospital, Outcome Assessment, Health Care, Prospective Studies, Surgery Department, Hospital

Introduction

The increasing prevalence of chronic kidney disease warrants the development of appropriate therapeutic strategies to manage its complications [1]. Maintenance hemodialysis (MHD) is a key therapeutic technique for patients with end-stage renal failure that requires a stable vascular access route [2]. The arteriovenous fistula (AVF) is considered the criterion standard for vascular access in hemodialysis due to its better durability and lower complication rates when compared to other access types [3–6]. However, AVF stenosis, which is defined by the narrowing of the fistula, remains a substantial concern, potentially jeopardizing dialysis efficacy and patient outcomes [7,8].

Traditionally, AVF stenosis interventions have relied on inpatient procedures, which generally necessitate hospital stays of at least 24–48 hours. In this inpatient model, surgical revision is often the primary intervention, involving direct access and modification of the stenosed segment. This may include removing obstructive tissue or bypassing the narrowed section entirely. The inpatient approach allows for thorough monitoring of postoperative complications such as bleeding, infection, and thrombosis – issues that can compromise fistula function if not promptly managed [7,9,10]. While effective in addressing these complications, this inpatient model imposes considerable strain on healthcare resources and is often inconvenient for patients due to prolonged hospitalizations and recovery times. The prolonged hospital stays and associated costs necessitate exploring alternative models that maintain clinical efficacy while enhancing patient experience and reducing economic strain [11,12].

Day surgery, a model in which patients are admitted, treated, and discharged within the same day, has shown promise in many fields by improving patient satisfaction and optimizing healthcare resources [13–15]. This outpatient approach offers significant benefits by reducing the need for extended hospitalization, minimizing resource utilization, and enhancing patient convenience. Indeed, day surgery is increasingly used to replace eligible inpatient therapies, benefitting patients, surgeons, and hospital managers alike [16–18]. In the context of AVF stenosis intervention, day surgery techniques such as angioplasty are emerging as effective methods that may provide clinical outcomes comparable to the traditional inpatient approach, with the added benefit of shorter hospital stays and lower costs.

This study investigated the feasibility and effectiveness of a day surgery model for AVF stenosis intervention in MHD patients. Specifically, this study utilized angioplasty as the day surgery technique to treat AVF stenosis and evaluated clinical outcomes, hospitalization costs, and complication rates between outpatient (day surgery) and inpatient (traditional surgery) approaches, seeking to establish a high-quality, low-cost model that could revolutionize the management of AVF stenosis in hemodialysis patients.

The primary objective of this study was to determine whether the day surgery model for AVF stenosis intervention can achieve outcomes comparable to the inpatient model. Specifically, we examined the success rates of the procedures, postoperative complication rates, and the economic implications of both approaches. This study hypothesized that the day surgery model would not be inferior to the inpatient model regarding clinical efficacy, while offering advantages in terms of reduced hospital stay and cost-efficiency. The goal of this study was to provide a theoretical basis for the broader adoption of day surgery in AVF stenosis treatment, potentially setting a new standard in care of MHD patients.

Material and Methods

STUDY DESIGN AND SETTING:

This study was conducted as a prospective cohort study from July 1, 2022, to May 31, 2023, at the Department of Nephrology, Beijing Haidian Hospital (China). The objective was to explore the feasibility of a day surgery model for treatment of AVF stenosis in MHD patients. We compared the outcomes of a day surgery model (observation group) with those of a conventional inpatient surgery model (control group). The study received approval from the Beijing Haidian Hospital Medical Ethics Committee (BHHMEC-XM-2022-02). All participants provided written informed consent in accordance with the Declaration of Helsinki.

PARTICIPANTS:

Eligible participants included patients aged 18–80 years diagnosed with AVF stenosis, meeting the inclusion criteria for intervention. Patients were divided into 2 groups based on their preference: the observation group undergoing day surgery and the control group undergoing inpatient surgery.

Inclusion criteria were: 1) Age 18–80 years; 2) Clear diagnosis of AVF stenosis with indications for intervention (local stenosis rate >50%, natural blood flow of the fistula <500 ml/min, or other related clinical symptoms); 3) Ability to understand and comply with perioperative care; 4) Controlled chronic diseases (eg, hypertension, diabetes, coronary heart disease); and 5) Residence within 200 kilometers of the hospital.

Exclusion criteria were: 1) Clinically suspected central venous stenosis; 2) Severe liver disease or coagulation dysfunction; 3) Active bleeding within the past 2 weeks; 4) Inability to cooperate due to mental illness; and 5) Refusal to sign informed consent.

PREOPERATIVE PREPARATION:

All participants underwent a series of preoperative evaluations, including blood tests, coagulation function, liver and kidney function tests, electrolytes, ECG, and AVF color ultrasound. Preoperative preparation also included signing surgical informed consent.

SURGICAL PROCEDURE:

The intervention procedures were performed under local infiltration anesthesia using a standardized protocol designed specifically for angioplasty in an outpatient setting. The steps included the following: 1) Disinfection and Anesthesia: Routine disinfection and administration of local anesthesia with 1% lidocaine at the target lesion site. 2) Introducer Sheath Insertion: Under real-time ultrasound-guided insertion of a 4–6F catheter sheath (Radiofocus Introducer II sheath, Terumo Corp., Tokyo, Japan), immediately followed by heparin injection at a dose of 50 IU per kilogram of body weight to reduce thrombosis risk. 3) Balloon Angioplasty: A hydrophilic 0.035-inch guidewire (Glidewire; Terumo Interventional Systems, Somerset, NJ) was used to navigate the balloon catheter to the stenotic segment. Balloon dilation was performed using 3–7 mm balloon catheters (Gladiator; Boston Scientific, Marlborough, MA), maintained for 30–60 seconds, repeated 2–3 times if necessary. For more severe stenoses, a 5–6 mm Peripheral Cutting Balloon (PCB; Boston Scientific) or an ultra-high-pressure balloon catheter (Conquest; Bard Peripheral Vascular, Tempe, AZ) was employed as needed. If cutting balloon (CB) angioplasty was performed, the balloon size was matched 1: 1 to the reference vessel diameter. The balloon was then slowly inflated to its nominal pressure of 6 atmospheres. If full inflation was not achieved at this pressure, the pressure was gradually increased to a burst threshold of 10 atmospheres. 4) Postoperative Evaluation: Following the procedure, ultrasound was used to evaluate the AVF for any residual stenosis, blood flow, and potential complications such as hematoma or pseudoaneurysm formation. Postoperative care included anticoagulant therapy and vigilant monitoring of vital signs and fistula status.

POSTOPERATIVE CARE:

Patients in the observation group were discharged after 2 hours of postoperative observation, while those in the control group were discharged after a 2-day observation period. Follow-up included telephone consultations on days 3 and 7 and an outpatient visit on day 30 for AVF patency evaluation. Long-term AVF patency was assessed at 6 months and 12 months after surgery.

BASIS FOR DETERMINING SAMPLE SIZE:

This non-inferiority trial compared day surgery to non-day surgery for the treatment of AVA stenosis. The surgical success rate was utilized as the primary evaluative metric to determine sample size. Previous research reported a 95.5% success rate for day surgery. The experimental and control groups were supposed to have the same success rate, with a non-inferiority margin of 10%. A 2: 1 intergroup ratio design was used. The sample size was obtained using the following formula:

For a test level α of 0.025 and β of 0.2, 112 and 56 cases were needed for the experimental and control groups, respectively. With a 10% loss to follow-up, the total sample size required was 186 cases.

OUTCOME MEASURES:

Primary and secondary outcomes were assessed to evaluate the efficacy and safety of the day surgery model. Primary outcomes were procedural success rate, defined by postoperative AVF palpation with thrill, ultrasound showing residual stenosis <30%, and successful completion of at least 1 hemodialysis session. Secondary outcomes were complication rate; 30-day, 6-month, and 12-month AVF patency rates; 30-day rehospitalization rate; hospitalization costs (Nursing Fee, Pharmacy, Surgery Fee, Medical Services, Consumables, Diagnostic Services, and Laboratory Fee); and average hospital stay.

STATISTICAL ANALYSIS:

Data were analyzed using SPSS 22.0. Measurement data with normal distribution are expressed as mean±standard deviation (χ±S) and compared using independent-sample t tests. Data with non-normal distribution are expressed as median (M±Q), and intergroup differences were tested using the non-parametric Mann-Whitney U test. Categorical variables were tested using chi-square tests. A P value of <0.05 was considered statistically significant.

DATA MANAGEMENT:

A dedicated research record book was used to record data. Recorded data was entered into the follow-up monitoring system on a regular basis. Case report forms were utilized to collect and summarize information for each patient, and the consistency with the original medical record was examined rigorously.

Results

PATIENT DEMOGRAPHICS AND BASELINE CHARACTERISTICS:

A total of 186 patients were enrolled in this study, with 112 patients in the day surgery group and 74 patients in the ward group, as illustrated in Figure 1. In the day surgery group, 56 subjects were males (50%) and 56 were females (50%), while the ward group comprised 31 males (41.89%) and 43 females (58.10%). The mean age of patients in the day surgery group was 62.5 years (IQR: 55.3–69.0), and for the ward group, it was 61 years (IQR: 51.5–70.0). There were no significant differences between the groups in terms of preoperative sex, age, dialysis age, or fistula age. Additionally, the prevalence of diabetes, coronary heart disease, and peripheral vascular disease did not differ significantly between the 2 groups, as reported in Table 1.

SURGICAL OUTCOMES AND HOSPITALIZATION METRICS IN DAY SURGERY AND WARD GROUPS:

The preoperative brachial artery diameter and blood flow rate were equivalent in both groups, with no statistically significant differences found, as shown in Table 2. Both groups achieved high intraoperative technical success rates, with the day surgery group at 99.11% and the ward group at 97.30%. The rate of intraoperative complications, including infection, hematoma, and thrombosis, was also modest, with no significant difference between the groups. Patients in the day surgery group had significantly shorter wait times for beds (P<0.0001) and hospital stays than those in the ward group (P<0.0001). Furthermore, cost analysis revealed a significant reduction in non-consumable costs for the day surgery group (Table 3), with lower median nursing fee, including room and care, supply and devices, and service fee, pharmacy expenses, and medical services (P<0.01). In contrast, surgery fees, including surgical supplies and devices, anesthesia, and operating room services, consumable costs, laboratory fee, and diagnostic services, remained similar in both groups (P>0.05). These findings underscore the cost-effectiveness of the day surgery model while maintaining comparable clinical outcomes.

POSTOPERATIVE PATENCY AND COMPLICATIONS:

Follow-up evaluations were conducted on postoperative days 1, 3, 7, and 30. At 30 days after surgery, the primary patency rate of AVFs was assessed using color Doppler ultrasound. As indicated in Table 2, postoperative outcomes such as brachial artery diameter and blood flow rate did not differ significantly between the groups. The 30-day readmission rate was 0% in the day surgery group and 1.35% in the ward group, with no statistically significant difference (χ2=0.04379, P=0.8342), as shown in Table 4. At 6 months, the primary patency rate was 82.14% for day surgery and 82.43% for inpatient procedures (χ2=0.0002560, P=0.9596), indicating no significant difference. After 6 months, the day surgery group had a cumulative patency rate of 100%, while the ward group had 97.3% (χ2=1.047, P=0.3063). After 1 year, the day surgery group had a primary patency rate of 66.96%, while the ward group had a rate of 58.11% (χ2=1.507, P=0.2196). The cumulative patency rate remained at 100% for the day surgery group and 97.3% for the ward group (χ2=1.047, P=0.3063). Over a 12-month follow-up period, these findings indicate that the day surgery paradigm for AVF stenosis intervention achieves equivalent outcomes to the standard inpatient strategy in terms of patency rates and complication frequencies.

Discussion

AVF stenosis is a common complication in MHD patients, often requiring timely and effective intervention to ensure adequate dialysis [7,8]. Traditional inpatient surgery, while effective, poses challenges such as longer hospital stays and increased healthcare costs [7,9,10]. This study aimed to evaluate the feasibility and effectiveness of a day surgery model for AVF stenosis intervention. The goal was to offer a high-quality, cost-effective alternative that improves patient experience while reducing the economic burden on patients and the healthcare system by addressing the urgent need for more efficient healthcare delivery methods.

Our findings indicate that the day surgery paradigm is comparable to inpatient surgery in terms of technical success and postoperative outcomes. The technical success rate was especially high in both groups, at 99.11% in the day surgery group and 97.30% in the ward group. This shows that day surgery can produce immediate procedural results similar to those with regular inpatient treatments. The complication rates were likewise comparable, indicating that day surgery does not increase the likelihood of adverse events. One notable difference was a significantly shorter hospital stay in the day surgery group, demonstrating the model’s efficiency. Patients in the day surgery group had an average stay of 2 hours after surgery, compared to 2 days in the ward group. This shorter hospitalization not only increases bed availability but also lowers the overall economic burden on the healthcare system and patients. Despite the shorter stay, the day surgery group did not have higher 30-day rehospitalization rates, demonstrating the safety and efficacy of early discharge. Furthermore, the day surgery model demonstrated comparable primary and cumulative patency rates at 6 months and 12 months, indicating its effectiveness in maintaining AVF patency. These findings suggest that the day surgery model provides similar long-term outcomes to the traditional inpatient model.

In terms of costs, day surgery proves to be a more cost-effective option than ward care, with significantly lower costs for nursing, pharmacy, and medical services, while costs for consumables, surgery, diagnostics, and laboratory fees remain similar in these 2 care models. This shows that the day surgery model may be a more cost-effective choice, particularly given the reduction in resource consumption and hospital occupancy. The study also highlights the advantages of the day surgery strategy for improving patient outcomes. Patients in the day surgery group expressed greater satisfaction with the convenience of shorter hospital stays and the chance to return home sooner. This methodology also supports the goal of minimizing disturbances to patients’ lives and lowering the psychological stress associated with extended hospital stays.

However, there are some limitations to this study. We acknowledge that a longer follow-up would provide more comprehensive insights into long-term AVF patency, associated complications, and quality of life outcomes. We recommend that future research incorporate longer follow-up periods to further validate and expand upon these findings. Furthermore, the study was conducted in a single location; therefore, the results may not be applicable to different contexts. Future research should include more centers and longer follow-up periods to further validate these findings.

Conclusions

In conclusion, this study is significant given the increasing number of patients requiring maintenance hemodialysis and the resulting load on healthcare systems. The implementation of a day surgery model for AVF stenosis intervention could have a substantial impact on healthcare practice, especially in resource-constrained countries. The day surgery model for treating AVF stenosis in MHD patients is feasible and successful, with similar technical success and complication rates to the standard inpatient surgery model. The significant reduction in hospital stays and associated cost savings make the day surgery model an appealing option. This approach improves patient satisfaction and well-being while also optimizing healthcare resource consumption. Finally, the success of this approach may be applied to other surgical treatments in MHD patients, encouraging wider applications of day surgery.

Data Availability Statement

All relevant data associated with this study are not publicly available within the article. These data belong to the research dataset of the institution of the authors and are subject to specific ethical and privacy constraints. However, we are willing to provide the necessary data to qualified researchers for the verification of the study results, upon reasonable request and in compliance with all applicable laws and regulations. Interested researchers may make data requests by contacting the corresponding author of the article.

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