Hemodialysis Reliable Outflow Graft Research Articles

Immediate Access Arteriovenous Grafts Decrease Catheter Days and Complications

Introduction - Immediate-access arteriovenous grafts (IAAVG) can be used as peripheral access or in combination with outflow through the Hemodialysis Reliable Outflow (HeRO) graft. This study compares IAAVG to standard arteriovenous grafts (SAVG) as well as describing IAAVG use with HeRO outflow. Methods - All patients who underwent placement of AV graft from 1/2014 - 4/2016 at two large tertiary referral centers were retrospectively identified in the electronic medical record and through the Vascular Quality initiative (VQI). Patients were divided into three groups based on the type of graft implanted (SAVG and IAAVG) and a third group of HeRO/IAAVG. Patient comorbidities, graft configuration, operative characteristics and subsequent follow-up were collected and analyzed with respect to primary patency, primary assisted patency, and secondary patency. Additional outcomes included graft-related complications, time to first canulation, time to tunneled catheter removal, catheter-related complications and overall survival. Patency was defined per Society for Vascular Surgery recommended reporting standards and was determined from the time of the index procedure. Chi-square, Kaplan-Meier and Cox regression analysis were used with the p-value set as significant at <0.05 Results - 254 grafts were identified; 148 SAVG, 62 IAAVG, 44 combined IAAVG-HeRO. Patient characteristics were similar between groups, except for more pre-operative central venous occlusions in the IAAVG vs SAVG (16.3% vs 6.8%, p<0.04) and these vs IAAVG/HeRO (100%, P<.001) . Of the IAAVG group, 50 were Acuseal (Gore) and 12 were Flixene (Atrium). IAAVG/HeR0 patients all used Acuseal. Standard AVG were all ePTFE (Gore Medical). Overall primary, primary assisted, and secondary patency at 6 months were 35.9%, 43.6%, and 51.3% respectively for IAAVG/HeRO. Primary patency at 1 year (SAVG: 39.4%, IAAVG: 56.7%, p=0.4), and secondary patency (SAVG: 50.7%, IAAVG: 52.1%, p=0.73) showed no significant differences. Similarly, there were no significant differences in primary (SAVG: 29.0%, IAAVG: 43.7%, p=0.4) or secondary patency (SAVG: 42.3%, IAAVG: 46.3%, p=0.73) at 18 months. Regression analysis did not show any association to the type of graft; however, IAAVG patients required fewer additional procedures to maintain patency (mean number of procedures 0.99 SAVG vs. 0.61 IAAVG, p=0.025). There was no difference in steal syndrome (SAVG: 6.8%, IAAVG: 8.1%, p=0.74).) or graft infection (19.0% SAVG vs. 12.0% IAAVG, p=0.276). 75% of all grafts were successfully canulated, with shorter median time to first canulation in the IAAVG group (6 days IQR 1-19) compared to the SAVG group (31 days, IQR 26-47) (p<0.01). For IAAVG/HeRO) patients, 95% of grafts were successfully canulated with mean time to canulation of 13.0±51.6 days. 53% of IAAVG/HeRO patients left the OR with this graft as their only access. This group had 100% canulation success at < 24 hours. 65.75% of all pre-existing catheters were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR 22-50) versus 49 days (IQR 39-67) in the SAVG group (p<0.01). Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs. 2.9%, p<0.045). Conclusion - IAAVGs allow earlier canulation and tunneled catheter removal, thereby significantly decreasing catheter-related complications. Patency and infection rates were similar between SAVG and IAAVG, but with fewer secondary procedures performed in IAAVG.

The inside-out technique for tunneled dialysis catheter placement with central venous occlusion

The “inside-out” technique eliminates the need for subclavian or femoral catheter placement by placing a supraclavicular catheter via a percutaneous femoral vein access. Few reports of its use in vascular surgery exist. The purpose of this article is to describe our version of the technique and report results. Between 2016 and 2017, the inside-out technique was performed on eight patients. All patients had more than four prior access sites and bilateral internal jugular vein occlusion. The technical success rates were 100% with no periprocedural complications and success in achieving dialysis access. One patient required catheter replacement within 48 hours, one catheter was used as a bridge to Hemodialysis Reliable Outflow (Hemosphere, a Cryolife Inc Company, Eden Prairie, Minn) graft placement, and one patient died of sepsis unrelated to their catheter. Our data show the inside-out technique to be safe and effective, removes the need for subclavian or femoral catheter placement, and should be a component of treatment algorithms for complex dialysis patients, which is consistent with National Kidney Foundation's Kidney Disease Outcomes Quality Initiative recommendations.

Quality of Life of Patients Using the Hemodialysis Reliable Outflow (HeRO) Graft in Hemodialysis.

End-stage renal disease (ESRD) is one of the most feared consequences of kidney disease. A large number of patients with ESRD require long-term hemodialysis. Vascular access options for hemodialysis include the placement of arteriovenous (AV) fistulas, AV grafts, and tunneled dialysis catheters (TDCs). An alternative to the TDC is the Hemodialysis Reliable Outflow (HeRO; Cryolife Inc., Eden Prairie, MN, USA) Graft. The HeRO Graft has been designed to overcome the development of central venous stenosis or occlusion. The objective is to evaluate the quality of life of patients using the HeRO Graft in end-stage renal disease for hemodialysis. We searched PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINHAL), Directory of Open Access Journals (DOAJ), Pubpsych, and Google Scholar on October 30, 2018. We included published articles in the English language that used the HeRO Graft for ESRD. The adequacy of dialysis and bacteremia rates proved to be equal to those of conventional AV grafts. It turned out that 2.21 interventions per year were needed to maintain the patency of the HeRO Graft while only 1.17 interventions were needed to maintain the patency of the lower extremity graft. Mortality, ischemia, and infection rates were similar for both groups. The tunneled dialysis catheters have a higher incidence of infection as compared to the HeRO Graft. The initial device and placement costs for the HeRO Graft were higher than those for TDCs but savings from the lower incidence of device complications and longer effective device patency make it cost-effective. Based on the limited evidence, it has been discerned that the HeRO Graft is an optimal option for hemodialysis in patients of ESRD who have exhausted all means of upper extremity access. Though almost similar to the AV grafts in terms of complications and less functional than femoral grafts, it still outclasses them in improving the quality of life of such patients.

Esophageal Varices: Itʼs Not Always an Uphill Battle

Downhill (proximal) esophageal varices (DEV) are a separate and distinct entity from the more common uphill (distal) esophageal varices. DEV are produced when an obstruction of the superior vena cava (SVC) leads to a downward flow of the venous system towards the portal vein. DEV are rarely seen as the cause of an acute upper gastrointestinal bleed and account for about 0.1% of all cases of variceal bleed. While there are many causes of SVC obstruction, catheter-associated SVC stenosis is the most frequently reported etiology in patients presenting with an acute variceal bleed. A 66 year old man with history of end stage renal disease on dialysis complicated by difficult access status post right upper extremity hemodialysis reliable outflow (HeRO) graft presented with melena and hemoglobin of 5.3 gm/dL. He underwent urgent endoscopy that demonstrated 3 columns of large proximal esophageal varices originating from the proximal esophagus and extending distally, one with nipple sign indicative of recent bleeding that was successfully banded. Abdominal ultrasound showed normal liver size and echogenicity. Hepatic enzymes were within normal limits (AST 24 U/L, ALT 25 U/L, and ALP 122 U/L). CT chest revealed no evidence of portal hypertension, however extensive chest wall venous collaterals were noted concerning for central venous stenosis. Vascular surgery was consulted for HeRO graft removal prior to IR stenting of SVC stenosis with no further evidence of bleeding. DEV are a rare form of varices seen as a result of SVC occlusion. Obstruction of the SVC shunts blood from systemic circulation into the esophageal plexus, predominantly the upper two-thirds. Bleeding DEV are most frequently noted in patients with central venous catheters. This is only the second case reported of a patient with SVC stenosis due to HeRO graft leading to DEV. There are no definitive recommendations on how to manage DEV, but addressing the underlying obstruction is the mainstay in treatment. There has been no data to address the use of somatastatin analogues for the use of bleeding DEV, although they would likely be of little benefit as the underlying etiology of DEV is not related to portal hypertension. Endoscopy and banding however do have a role in temporizing active bleeding. There is also currently no evidence on the use of beta-blockers for secondary prevention as relieving the obstruction should be a priority to prevent further bleeding.1810_A Figure 1. Gastroesophageal junction1810_B Figure 2. Proximal to mid-esophagus1810_C Figure 3. Esophageal varices post banding

Safety and efficacy of a modified HeRO dialysis device in achieving early graft cannulation: A single-institution experience

Hemodialysis Reliable Outflow (HeRO) grafts (Merit Medical Systems, Inc, South Jordan, Utah) provide a means for access in catheter-dependent hemodialysis patients but typically require several weeks for tissue incorporation. Modifying the HeRO graft with an ACUSEAL graft (W. L. Gore & Associates, Newark, Del) can allow immediate cannulation, thus reducing catheter dependence time and its associated complications. A retrospective review of patients at our institution from 2013 to 2016 who underwent placement of a modified HeRO dialysis system with ACUSEAL graft was performed. Complications and outcomes were analyzed, with patency rates and hours to successful cannulation being major end points. Modified HeRO grafts were successfully placed in 10 catheter-dependent patients. Postoperative complications included two thromboses and one hematoma. At 6 months of follow-up, mean time to graft cannulation was 33.7 hours, with 100% success; the primary and secondary patency rates were 70% and 90%, respectively. Our modification allows an accelerated use of the HeRO system, reducing catheter dependence time with acceptable postoperative complications and patency rates.

Primary and secondary patencies of transposed femoral vein fistulas are significantly greater than with the HeRO graft

For access-challenged patients with bilateral upper extremity central venous stenosis, solutions include the Hemodialysis Reliable Outflow (HeRO) device or an autogenous AV fistula in the lower limb. We evaluated HeRO grafts and transpositions of the femoral vein in maintaining primary and secondary patency. We retrospectively analyzed 40 patients with a HeRO device and 18 patients with superficial femoral artery to transposed femoral vein autogenous arteriovenous fistula (SFA-tFV). All patients had bilateral central venous obstruction. All procedures were outpatient performed by a single surgeon at one center between 2009-2015. Operative details, intraoperative flows, and flows at the first-week postoperative visit were analyzed, as were primary and secondary patency and intervention rates. Complications were compared between groups. The one-year cumulative primary patency was 30% for HeRO grafts and 79% for SFA-tFV fistulas (p = 0.0001); secondary patency was 71% for HeRO grafts and 93% for SFA-tFV fistulas (p = 0.03). To maintain patency, HeRO patients required a mean 2.1 interventions per year and thigh fistula patients required a mean 0.4 interventions per year. Thirty-seven percent of thigh fistula patients had a hematoma or seroma versus 5% of HeRO patients and 17% of thigh fistula patients experienced delayed wound healing versus 2.5% of HeRO patients (p<0.05). None of the thigh fistula patients had distal ischemia. HeRO patients had lower primary and secondary patency rates versus thigh fistula patients and HeRO grafts required five-fold more interventions to maintain secondary patency. However, patients with thigh fistulas had significantly more wound healing problems. Thus, the SFA-tFV has become our access of choice for patients with bilateral central venous stenosis.

Abstract No. 141 - Management of central venous stenosis in hemodialysis patients: comparison of outcomes with the Hemodialysis Reliable Outflow (HeRO) graft versus stenting

To evaluate outcomes of HeRO graft placement and compare its efficacy to central venous stenting in hemodialysis patients with recalcitrant central venous stenosis. We performed a retrospective review of hemodialysis patients who underwent HeRO graft placement or stenting for central venous stenosis between January 2010 and September 2016. The fraction of patients requiring no further intervention, the post-intervention primary lesion patency and number of interventions per patient year for both groups were analyzed. We identified 29 patients with a total of 30 HeRO graft placement procedures. Two patients with no follow-up information after graft placement were excluded from this study. One patient whose HeRO graft was removed due to infection had a repeat HeRO graft placement. We also identified 14 patients who underwent stenting for their central venous stenosis. At the time of this interim analysis, in the HeRO group, 16/28 (57%) were still patent with no further intervention after the graft placement, with a mean follow-up time of 582 days (± 532). In the stent group, 4/14 (28%) were still patent with no further intervention after stenting, with a mean follow up of 579 days (± 371). Among patients requiring an intervention, mean post-intervention primary lesion patency for the HeRO graft (N = 12) was 479 days versus 332 days for the stent group (N = 10). The average number of interventions per patient year for the HeRo and stent groups were 1.4 and 2.3, respectively. Student’s t-test for post-intervention primary lesion patency and number interventions per year for the two groups showed no statistically significant differences (p-values: 0.115 and 0.401, respectively). For the stent group, mean number of intervention per year for covered stent (N = 4) was 0.43 versus 2.12 for non-covered stent (N = 10). Our preliminary analysis of this ongoing study shows no statistically different outcome in patients treated with the HeRO graft versus stenting for central venous stenosis. HeRO is a viable option for hemodialysis patients with recalcitrant central stenosis who are non-surgical candidates for AV fistula.

Not Quite a Hero (Hemodialysis Reliable Outflow Graft): A Rare Cause of Dyspnea and Positional Syncope in End Stage Renal Disease (ESRD)

Not Quite a Hero (Hemodialysis Reliable Outflow Graft): A Rare Cause of Dyspnea and Positional Syncope in End Stage Renal Disease (ESRD)

Early infection risk with primary versus staged Hemodialysis Reliable Outflow (HeRO) graft implantation

ObjectiveThis study evaluated whether the use of a staged Hemodialysis Reliable Outflow (HeRO; Merit Medical, South Jordan, Utah) implantation strategy incurs increased early infection risk compared with conventional primary HeRO implantation. MethodsA retrospective review was performed of 192 hemodialysis patients who underwent HeRO graft implantation: 105 patients underwent primary HeRO implantation in the operating room, and 87 underwent a staged implantation where a previously inserted tunneled central venous catheter was used for guidewire access for the venous outflow component. Within the staged implantation group, 32 were performed via an existing tunneled hemodialysis catheter (incidentally staged), and 55 were performed via a tunneled catheter inserted across a central venous occlusion in an interventional radiology suite specifically for HeRO implantation (intentionally staged). Early infection was defined as episodes of bacteremia or HeRO infection requiring resection ≤30 days of HeRO implantation. ResultsFor staged HeRO implantations, the median interval between tunneled catheter insertion and conversion to a HeRO graft was 42 days. The overall HeRO-related infection rate ≤30 days of implantation was 8.6% for primary HeRO implantation and 2.3% for staged implantations (P = .12). The rates of early bacteremia and HeRO resection requiring surgical resection were not significantly different between groups (P = .19 and P = .065, respectively), nor were age, gender, laterality, anastomosis to an existing arteriovenous access, human immunodeficiency virus status, diabetes, steroids, chemotherapy, body mass index, or graft location. None of the patient variables, techniques, or graft-related variables correlated significantly with the early infection rate. ConclusionsThe staged HeRO implantation strategy did not result in an increased early infection risk compared with conventional primary implantation and is thus a reasonable strategy for HeRO insertion in hemodialysis patients with complex central venous disease.

A comparison of patency and interventions in thigh versus Hemodialysis Reliable Outflow grafts for chronic hemodialysis vascular access

With improvements in medical management and survival of patients with end-stage renal disease, maintaining durable vascular access is increasingly challenging. This study compared primary, assisted primary, and secondary patency, and procedure-specific complications, and evaluated whether the number of interventions to maintain or restore patency differed between prosthetic femoral-femoral looped inguinal access (thigh) grafts and Hemodialysis Reliable Outflow (HeRO; Hemosphere Inc, Minneapolis, Minn) grafts. A single-center, retrospective, intention-to-treat analysis was conducted of consecutive thigh and HeRO grafts placed between May 2004 and June 2015. Medical history, interventions to maintain or restore patency, and complications were abstracted from the electronic medical record. Data were analyzed using parametric and nonparametric statistical tests, Kaplan-Meier survival methods, and multivariable proportional hazards regression and logistic regression. Seventy-six (43 thigh, 33 HeRO) grafts were placed in 61 patients (54% male; age 53 [standard deviation, 13] years). Median follow-up time in the intention-to-treat analysis was 21.2months (min, 0.0; max, 85.3months) for thigh grafts and 6.7months (min, 0.0; max, 56.3months) for HeRO grafts (P= .02). The groups were comparable for sex, age, coronary artery disease, diabetes mellitus, peripheral vascular disease, and smoking history (all P ≥ .12). One thigh graft (2%) and five HeRO (15%) grafts failed primarily. In the intention-to-treat analysis, patency durations were significantly longer in the thigh grafts (all log-rank P ≤ .01). Point estimates of primary patency at 6months, 1year, and 3years were 61%, 46%, and 4% for the thigh grafts and 25%, 15%, and 6% for the HeRO grafts. Point estimates of assisted primary patency at 6months, 1year, and 3years were 75%, 66%, and 54% for the thigh grafts and 41%, 30%, and 10% for the HeRO grafts. Point estimates of secondary patency at 6months, 1year, and 3years were 88%, 88%, and 70% for the thigh grafts and 53%, 43%, and 12% for the HeRO grafts. There were no differences in ischemic (P= .63) or infectious (P= .79) complications between the groups. Multivariable logistic regression demonstrated that after adjusting for follow-up time, HeRO grafts were associated with an increased number of interventions (P= .03). Thigh grafts have significantly better primary, assisted primary, and secondary patency compared with HeRO grafts. There is no significant difference between thigh grafts and HeRO grafts in ischemic or infectious complications. Our logistic regression model demonstrated an association between HeRO grafts and an increased number of interventions to maintain or restore patency. Although HeRO grafts may extend the use of the upper extremity, thigh grafts provide a more durable option for chronic hemodialysis.

Obesity Increases the Risk of Primary Nonfunction and Early Access Loss, and Decreases Overall Patency in Patients Who Underwent Hemodialysis Reliable Outflow Device Placement

Hemodialysis reliable outflow (HeRO) catheters were introduced in 2008, and have been since providing a reliable alternative for hemodialysis patients who are deemed "access challenged." However, its outcomes have not been extensively investigated due to its relatively young age. Here, we report our 6-year single institution experience, and demonstrate the significant impact of obesity on HeRO graft outcomes, an aspect not previously studied in the literature. Patients who underwent HeRO graft placement at the University of Illinois Hospital between April 2009 and August 2015 were included retrospectively. Data were collected from patients' electronic medical records and analyzed using SPSS software. Thirty-three patients who underwent 34 HeRO catheter placements were included. Mean age was 47±12years, and mean body mass index (BMI) was 30.75±10.22. Median follow-up was 635days. Overall catheter-related complications were thrombosis (70.59%), infection (20.59%), arterial steal (8.82%), and pseudoaneurysms requiring intervention (8.82%). Overall primary and secondary patency rates after 6 and 12months were 31.25%, 25%, 78.13%, and 71.86%, respectively. Primary nonfunction rate was 14.7%. Obese patients had significantly higher rate of primary nonfunction (38.46% vs. 0%, P=0.0046), and relative risk 3.62 (95% confidence interval [CI] 2.01-6.52). They also had a significantly decreased rate of graft patency after 12months (10.53% vs. 53.85%, P=0.0227), leading to a relative risk of "early" graft loss within 1year of 5.12 (95% CI 1.26-20.83). Overall median graft patency in obese patients was significantly shorter than that of nonobese patients (311 vs. 1295 days, P=0.014). BMI, as a continuous variable, was a significant predictor of primary nonfunction (P=0.046) and early graft loss (0.020) when tested against age, sex, race, and diabetes in a multivariate logistic regression analysis. HeRO catheters offer a reliable, and possibly the last, alternative in hemodialysis access-challenged patients. In our population, obesity was a significant risk factor for primary nonfunction, early graft loss, and a shorter overall graft patency. BMI, as a continuous variable, can serve as a predictor of primary nonfunction and early graft loss after adjustment for age, race, sex, and diabetes. Obesity's effect on HeRO catheters has not been amply addressed; therefore further prospective studies are warranted.

Cost analysis of the Hemodialysis Reliable Outflow (HeRO) Graft compared to the tunneled dialysis catheter

In end-stage renal disease patients with central venous obstruction, who have limited vascular access options, the Hemodialysis Reliable Outflow (HeRO) Graft is a new alternative with a lower incidence of complications and longer effective device life compared to tunneled dialysis catheters (TDCs). We undertook an economic analysis of introducing the HeRO Graft in the UK. A 1-year cost-consequence decision analytic model was developed comparing management with the HeRO Graft to TDCs from the perspective of the National Health Service in England. The model comprises four 3-month cycles during which the vascular access option either remains functional for hemodialysis or fails, patients can experience access-related infection and device thrombosis, and they can also accrue associated costs. Clinical input data were sourced from published studies and unit cost data from National Health Service 2014-15 Reference Costs. In the base case, a 100-patient cohort managed with the HeRO Graft experienced 6 fewer failed devices, 53 fewer access-related infections, and 67 fewer device thromboses compared to patients managed with TDCs. Although the initial device and placement costs for the HeRO Graft are greater than those for TDCs, savings from the lower incidence of device complications and longer effective device patency reduces these costs. Overall net annual costs are £2600 for each HeRO Graft-managed patient compared to TDC-managed patients. If the National Health Service were to reimburse hemodialysis at a uniform rate regardless of the type of vascular access, net 1-year savings of £1200 per patient are estimated for individuals managed with the HeRO Graft. The base case results showed a marginal net positive cost associated with vascular access with the HeRO Graft compared with TDCs for the incremental clinical benefit of reductions in patency failures, device-related thrombosis, and access-related infection events in a patient population with limited options for dialysis vascular access.

The use of HeRo catheter in catheter-dependent dialysis patients with superior vena cava occlusion.

Hemodialysis (HD) patients with superior vena cava (SVC) occlusion have limited access options. Femoral access is commonly employed but is associated with high complication rates. Hemodialysis Reliable Outflow (HeRO) catheters can be used in tunneled catheter-dependent (TCD) patients who have exhausted other access options. The HeRO graft bypasses occlusion and traverses stenosis with outflow directly into the central venous circulation. At our institution we have used the inside-out central venous access technique (IOCVA) to traverse an occluded vena cava for HeRO graft placement. We review our experience with this technique. A retrospective chart review was conducted of patients with HeRO graft placement at our institution. All were dependent on a tunneled femoral dialysis catheter due to central venous occlusion (CVO). The IOCVA technique was used in each case. This technique was used as last resort for patients who had no other dialysis access option. Demographics, patency rates, complications, and mortality were recorded. A total of 11 HeRO grafts were placed in 11 patients from January 2012 to June 2013, with 100% technical success rate. Three grafts were ligated due to steal syndrome. Two grafts were lost due to thrombosis. Five of 11 patients experienced a 30-day complication. Three patients died within the follow-up period; however, none were directly related to the graft placement. Follow up range was 65-573 days; 5 of 11 grafts were used for dialysis at the end of the follow-up period. The 12-month patency rate was 30%. HeRO grafts are one option for dialysis patients with CVO. There is, however, a high incidence of steal syndrome and other complications. These grafts should be offered as a final potential alternative to catheter dependence.

A 55-year-old female presenting with central venous stenosis

Introduction: Patients who have failed arteriovenous grafts (AVG) and arteriovenous fistulas (AVF) and are central venous catheter (cVc) dependent have a new option for hemodialysis access: the hemodialysis reliable outflow (HerO) graft. Our patient required hemodialysis for end-stage renal disease (EsrD) secondary to uncontrolled diabetes. case report: A 55-year-old female presented with multiple AV fistula and AV graft failures due to venous outflow obstruction. she was catheter-dependent for hemodialysis access with evidence of central venous stenosis. the patient also presented with ventilator-dependent respiratory failure on pressure support ventilation and recurrent pleural effusions due to volume overload. With all other options exhausted, she underwent HerO graft placement complicated by postoperative steal syndrome, and multiple thromboses. conclusion: the HerO graft is an option for long-term hemodialysis access for patients who are refractory to traditional approaches and are catheter-dependent. thrombosis and steal syndrome may be more common complications of the surgery than previously suspected, but may be manageable if caught early. In comparison to central venous catheters, with the HerO graft, infection rates are reduced and flow rate can be

Paradoxical Embolus following Percutaneous Thrombectomy of Hemodialysis Reliable Outflow Graft

Percutaneous interventions to maintain or re-establish patent vascular access are common and often necessary for patients on hemodialysis. This case illustrates an extremely rare but potentially devastating complication of one of these procedures: cerebrovascular insult due to paradoxical embolism in the setting of a patent foramen ovale.

Multidisciplinary team approach to end-stage dialysis access patients

BackgroundThe hemodialysis reliable outflow (HeRO) access device is a permanent dialysis graft used in patients with central venous obstruction. Given the complexity of care related to end-stage dialysis access (ESDA) patients, a multidisciplinary approach has been used to achieve operative success of HeRO graft placement. MethodsThe single-center retrospective review included adult patients that were seen in ESDA clinic who underwent a HeRO graft placement from September 2010–September 2014 under the care of a team consisting of a nephrologist, an interventional radiologist, and a surgeon. The effectiveness of the multidisciplinary approach was evaluated using outcome variables including successful HeRO graft placement, operative complications, the rate of obtaining central venous access, and advanced endovascular maneuvers performed by interventional radiology to obtain central venous access. ResultsA multidisciplinary approach has been used in 33 ESDA patients. Access to the right atrium was achieved in 100% of cases. Fifty-eight percent of patients required advanced endovascular maneuvers in the interventional radiology suite to obtain central venous access. Successful HeRO graft placement was achieved in 94% (31 of 33) of the study population. No intraoperative complications were encountered. Median primary and secondary patency rates were 83 d (interquartile range: 45–170) and 345 d (interquartile range: 146–579) per HeRO graft placement, respectively. Primary and secondary patency rates at 60 d were 70% (23 of 33) and 79% (26 of 33), respectively. ConclusionsIn this difficult patient population, a multidisciplinary team can provide a unique and collaborative approach to HeRO graft placement in patients with complex central venous outflow obstruction.

Two-stage Hemodialysis Reliable Outflow (HeRO) graft implantation technique that avoids the use of a femoral bridging dialysis catheter.

The purpose of this study is to report a novel two-stage Hemodialysis Reliable Outflow (HeRO) graft implantation technique that avoids the use of a femoral bridging hemodialysis catheter in internal jugular vein (IJV) catheter-dependent patients with contralateral central venous occlusion. The first stage is to implant the ePTFE component and consists of: 1) performing two to three incisions in the upper arm ipsilateral to the preexisting IJV catheter, 2) tunneling the expanded polytetrafluoroethylene (ePTFE) component through these incision sites, and 3) placing the ePTFE component in the subcutaneous tissue without anastomosing it to the target artery. The preexisting IJV catheter is maintained to provide continuous dialysis access. The second stage is initiated in 4 weeks and includes: 1) thrombectomy and anastomosing the ePTFE component arterial end to the target artery, 2) insertion of the venous outflow component using the preexisting IJV catheter access site, and 3) connecting the venous outflow component to the ePTFE component in the standard fashion. The HeRO graft was successfully implanted in two stages without using a femoral bridging catheter. Immediate postimplant cannulatabilty was achieved upon completion of the second stage procedure. This novel two-stage HeRO implantation technique is simple, yet allows immediate cannulation upon completion of the second stage procedure while avoiding the need of a femoral bridging catheter in IJV catheter- dependent patients with contralateral central venous occlusion, and thus lowering the risk of infection related to a femoral bridging catheter.

Report on the Hemodialysis Reliable Outflow (HeRO) experience in dialysis patients with central venous occlusions

The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, Minn) has provided an innovative means to obtain hemodialysis access for patients with severe central venous occlusive disease. The outcomes of this novel treatment modality in a difficult population have yet to be clearly established. A retrospective review of HeRO graft placement from June 2010 to January 2012 was performed. Patient hemodialysis access history, clinical complexity, complications, and outcomes were analyzed. Categoric data were described with counts and proportions, and continuous data with means, ranges and, when appropriate, standard deviations. Patency rates were analyzed using life-table analysis, and patency rate comparisons were made with a two-group proportion comparison calculator. HeRO graft placement was attempted 21 times in 19 patients (52% women), with 18 of 21 (86%) placed successfully. All but one was placed in the upper extremity. Mean follow-up after successful placement has been 7 months (range, 0-23 months). The primary indication for all HeRO graft placements except one was central vein occlusion(s) and need for arteriovenous access. Patients averaged 2.0 previous (failed) accesses and multiple catheters. Four HeRO grafts (24%), all in women, required ligation and removal for severe steal symptoms in the immediate postoperative period (P < .01 vs men). Three HeROs were placed above fistulas for rescue. All thrombosed <4 months, although the fistulas remained open. An infection rate of 0.5 bacteremic events per 1000 HeRO-days was observed. At a mean follow-up of 7 months, primary patency was 28% and secondary patency was 44%. The observed 12-month primary and secondary patency rates were 11% and 32%, respectively. Secondary patency was maintained in four patients for a mean duration of 10 months (range, 6-18 months), with an average of 4.0 ± 2.2 thrombectomies per catheter. HeRO graft placement, when used as a last-resort measure, has been able to provide upper extremity access in patients who otherwise would not have this option. There is a high complication rate, however, including a very high incidence of steal in women. HeRO grafts should continue to be used as a last resort.

Bilateral Pulmonary Emboli Secondary to Indwelling Hemodialysis Reliable Outflow Catheter

We present a 33-year-old dialysis-dependent female who presented with new onset split second heart sound. Following a failed left upper extremity dialysis fistula, a right upper extremity hemodialysis reliable outflow (HeRO) graft was performed in 2011. Her subsequent cadaveric renal transplant had delayed function necessitating concurrent use of hemodialysis. However, as renal function improved, hemodialysis was discontinued. Two weeks following transplantation, the HeRO graft occluded. Subsequent clinical and radiological assessment confirmed widespread pulmonary emboli. Following cessation of hemodialysis and subsequent HeRO graft occlusion, removal was deemed appropriate to reduce further thromboembolic phenomenon. Right atrial thrombi are complications associated with central venous catheters. However, their actual incidence varies significantly. Right heart thromboemboli are associated with a 4% to 6% pulmonary embolism rate. Katzman et al assessed 38 patients who underwent HeRO graft and reported 1 (2.6%) patient with right atrial emboli and likely pulmonary embolism. Although thrombotic complications remain rare, consideration of graft removal should always be evaluated particularly in the absence of an alternative thrombotic source.

Downhill Varices Secondary to HeRO Graft‐Related SVC Syndrome

Tunneled hemodialysis catheters are well-documented causes of benign central vein stenosis, which can be associated with proximal or downhill esophageal varices due to shunting of blood flow from the upper portion of the body through the esophageal venous plexuses. A majority of these cases remain asymptomatic. As a result, studies are largely limited to symptomatic patients, with incidence rates ranging from 16% to 29%. Recently, Hemodialysis Reliable Outflow (HeRO) graft has been introduced as an effective alternate hemodialysis access in catheter-dependent patients, especially in the presence of significant central venous occlusion. It differs from a conventional arteriovenous graft (AVG) by the fact that its venous outflow end is in the right atrium via one of the central veins, bypassing any significant occlusion upstream. Lower intervention rates and reduced incidence of bacteremia make it comparable to conventional tunneled catheters. However, the incidence of central vein occlusion and associated complications with HeRO grafts is unknown. We present the first case of gastrointestinal bleeding from downhill esophageal varices secondary to HeRO-graft-related SVC occlusion.