Patient selection must be conservative. There are no intensive care units, operating rooms, ventilators, blood banks, nor thoracotomy trays in an outpatient DAC. Hemodialysis patients are inherently at increased risk of cardiovascular morbidity and mortality [12]. It is important to be keenly aware of their history and physical condition prior to a procedure. Their volume status, coagulation profile, and respiratory state are essential factors to consider before the ambulatory procedure. Abnormalities in these specific systems portend an increased risk for complications. In addition to competency at BLS and ACLS, establishment and practice of protocols to deal with allergic reactions (many times radiologic contrast induced) should be instituted.

Contraindications for performing an access procedure in the outpatient center should include airborne disease, contact isolation for infection, ventilator dependence, severe anxiety, poor pain tolerance, documented severe dye allergy, heparin allergy (including heparin-induced thrombocytopenia), and morbid obesity (i.e., most manufacturers do not recommend moving the table top on anyone over 300–350 lbs.). Most importantly, there should be access to and a relationship with a nearby hospital to accept patients with complications or cardiovascular instability.

Airway assessments must be carefully made. Rapid access to equipment required to manage a respiratory crisis is necessary. This is important even if the patient is receiving no sedation but only local anesthesia, as recumbent positioning and anxiety can result in a change in the respiratory state of fragile patients. Moderate sedation must be cautiously managed. Employing an anesthesiologist or contracting with one is the safest course of action when performing procedures in the outpatient angiographic suite. This allows for the best clinical expertise in airway management and sedation to be available if anything untoward happens.

Radiation safety is paramount in an outpatient angiographic suite. A radiation safety officer is often hired as an independent contractor. Education for all staff regarding radiation safety policies and procedures is part of all state regulatory agency requirements. Radiation exposure must be minimized to staff, physicians, and patients. A policy for measuring the dose all individuals receive, including patients, should be in place. The delivered dose of radiation should be recorded and followed. Fluoroscopy time can be used as a surrogate of exposure. Lead aprons and other radiation protective devices and garments should be checked periodically for defects.

Multiple imaging modalities within an outpatient DAC may allow for optimization of dialysis access care [13]. Duplex ultrasound (DUS) allows for rapid noninvasive assessment of the dialysis access and can determine whether or not an intervention is required. Vein mapping prior to access placement can also be offered as a service. Many surgeons now request vessel mapping prior to dialysis access surgery. Preoperative vessel mapping has improved the placement and success of dialysis access creation [14]. This mapping is done in the DAC, but access creation is, currently, still required to be performed in an in-hospital setting for reimbursement from payers. Ultrasound can also be used to gain access to vasculature that is not readily palpable. This can improve the safety, success, and speed of peripheral vascular intervention performed in the outpatient center. Computed tomographic angiography (CTA) can complement ultrasound imaging by assessing structures not readily seen on sonography (i.e., central venous system). Magnetic resonance angiography (MRA) without contrast may also be an option as software and technology improves. Since CTA and MRA require an expensive capital purchase or lease arrangement, realistic forecasting and financial planning should be done prior to commitment to these technologies. In stark contrast, duplex ultrasound machines are less expensive and have more applicability to dialysis access patients.

Lack of access to care due to transportation difficulties, hours of operation, and health insurance continue to be obstacles for most outpatient facilities. Transportation to obtain medical care is a problem for some hemodialysis patients. Employing a social worker or coordinating with social workers in the dialysis units can help to solve many transport issues. Municipalities often have dedicated programs to help those who need to travel for medical care. The challenge is often in navigating the bureaucratic system. Contracting with a taxi service may be an option for ambulatory patients. Medical transport services are options especially for poorly mobile patients. The ideal DAC would have hours that mimic that of the referring hemodialysis center. This often means keeping the doors open on weekends and late afternoons. Many times this is not practical as there are cost and quality of life constraints for staff and providers. Outpatient DACs that have robust patient populations can, and do, offer flexible hours and more comprehensive availability. Some have relationships with local emergency departments and handle access emergencies, thereby avoiding hospital admissions for these patients. Emergent procedures comprise 20 % of the workload in a DAC. Kian and colleagues demonstrated that 61 % of patients referred emergently had successful dialysis within 24 h (90 % had successful dialysis within 48 h) [8]. Lack of access due to poor or no insurance coverage has been the hardest obstacle to overcome for nearly all outpatient DACs.

Accreditation, outcomes reporting, and quality initiatives are necessary for the future success of office-based procedures. Currently many different organizations accredit outpatient angiographic facilities – i.e., Accreditation Association for Ambulatory Health Care (AAAHC), Joint Commission on Accreditation of Health Care Organizations (JCAHO), etc. Though accreditation is not required, nor currently linked to reimbursement, it is highly recommended. It currently fills the vacuum that exists for setting standards for these facilities. Surrogates for quality are actively being sought in the delivery of healthcare, and accreditation will likely be a strong candidate. Outcomes reporting is robust in the inpatient setting, but it is very inconsistent in the outpatient arena. This is currently the Achilles heel of the outpatient DAC. By prospectively showing the quality and efficacy of the work done in the DAC, paradigms will shift. Quality initiatives relating to hemodialysis vascular access exist in the fields of nephrology, interventional radiology, and vascular surgery. Reporting through the DAC rather than disparately through multiple society registries will allow more comprehensive reporting and real-world analysis.