We describe the use of tumescent local anesthesia during endovascular treatment of arteriovenous fistula stenosis. Using ultrasound guidance, 11 patients were hand-injected with tumescent lidocaine anesthesia around the fistula stenosis prior to endovascular therapy. All patients rated the pain experienced during angioplasty on a numeric scale (0-10). The mean balloon inflation pressure was 12 ± 3.01 atm. During angioplasty, eight patients reported pain between 0 and 2; three patients reported 4, 5, and 7 out of 10 on the pain scale. In this small series, tumescent anesthesia provided adequate pain control to perform angioplasty of arteriovenous fistulas.

requirements, can be met by analyzing data already collected by the VL. After a process improvement strategy, we chose to review progress in our VL related to time to interpretation (TI), patient check-in to study completion (AWT), wait time for the first available outpatient venous duplex scan (WTAA), technologist productivity, and critical results reporting (CRR).Methods: Data from our hospital-based VL was collected from 2010 to 2016. TI was automatically collected through Vascupro (Consensus Medical), and AWT and WTAA were obtained from the electronic medical record (EMR; Epic). Technologist productivity was calculated by the formula in Fig 1 . Compliance with CRR was calculated annually per Intersocietal Accreditation Commission requirements. Appropriateness of carotid duplex scans was done by expert review of International Classification of Diseases codes.Results: The TI analysis included 91,352 studies with a mean of 3.3 hours. TI improved from 5.0 to 2.1 hours but was 4.9 hours longer on weekends (P < .001). The AWT improved from 29.8 to 27.2 minutes and was 14.9 minutes shorter on the weekends (P < .001). WTAA ranged from a mean of 1 to 2.08 days. Technologist productivity improved from 90.7% to 93.6% (Fig 2). Critical results reporting audits showed a 100% compliance rate. On expert review, the International Classification of Diseases code on carotid duplex scans in the EMR was deemed inaccurate in 17.4% of cases.Conclusions: TI and AWT improved and WTAA and CRR remained steady. Much of the data are readily available in a VL standard EMR. The "plan-do-study-act" principle of the Shewhart cycle is critical to process improvement and needed as we transition from traditional accreditation mostly based on accuracy to one demanding efficiency, productivity, accountability, and appropriateness of testing. These process improvement studies will improve patient care and institutional finances, while satisfying changing Intersocietal Accreditation Commission standards and upcoming regulatory requirements of MACRA.

Objective: In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex ultrasound stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation (SI), whether surveillance with ADSI yielded a better outcome than in those with only anklebrachial index (ABI) follow-up.Methods: We performed a retrospective analysis of all patients undergoing SFA SI for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI (ADSI group) and those with ABI follow-up only (ABI group). Life-table analysis comparing stent patency, major adverse limb event (MALE), limb salvage, and mortality between groups was performed.Results: There were 248 patients with SFA SI included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous regarding clinical indication (claudication/critical limb ischemia, ADSI 39%/61% vs ABI 38%/62%; P ¼ .982) and TransAtlantic Inter-Society Consensus classification (A/B/C/D for ADSI 17%/45%/16%/22% and ABI 21%/43%/16%/20%; P ¼ .874). Primary patency (PP) was similar between groups at 12, 36, and 56 months (ADSI, 65%/43%/32%; ABI, 69%/34%/34%; P ¼ .770), whereas ADSI patients showed an improved assisted PP (84%/68%/54%) vs ABI (76%/38%/38%; P ¼ .008) and secondary patency (Fig 1). There was a greater freedom from MALE in the ADSI group (91%/76%/64%) vs the ABI group (79%/46%/46%; P < .001) at 12, 36, and 56 months of followup. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA SI intervention (P ¼ .001), whereas ABI patients were more likely to undergo an amputation (P < .001; Fig 2).Conclusions: In SFA SI, patients with ADSI follow-up demonstrate an advantage in assisted PP and secondary patency and are more likely to undergo an endovascular reintervention. These factors likely effected a decrease in MALE, indicating the benefit of a more universal adoption of post-SFA SI follow-up ADSI.