Hemodialysis Reliable Outflow Research Articles

Contemporary Comparison Between the Hemodialysis Reliable Outflow Device and Femoral Arteriovenous Graft

Contemporary Comparison Between the Hemodialysis Reliable Outflow Device and Femoral Arteriovenous Graft

Fatal Budd-Chiari syndrome associated with Hemodialysis Reliable Outflow (HeRO) graft.

Population aging and prolonged time on dialysis pose challenges to vascular access for nephrologists and vascular surgeons. HeRO grafts are an option used for patients with central venous obstruction and without the possibility of other vascular access on upper limbs. Some long-term complications, namely access thrombosis, infection, and limb ischemia, have already been reported. There are few data on thromboembolic complications associated with this device. We report the first case in the literature of Budd-Chiari Syndrome associated with the HeRO graft.

Balloon-Targeted Extra-Anatomic Sharp Recanalization Technique to Re-establish Supraclavicular Vascular Access

A balloon-targeted extra-anatomic sharp recanalization (BEST) technique was investigated to re-establish supraclavicular vascular access in patients with central venous occlusion. Query of the authors’ institution’s database yielded 130 patients who underwent central venous recanalization. Of these, a retrospective review of 5 patients with concurrent thoracic central venous and bilateral internal jugular vein occlusions who underwent sharp recanalization using the BEST technique from May 2018 to August 2022 was performed. Technical success was achieved in all cases without major adverse events. Four (80%) of the 5 patients underwent hemodialysis reliable outflow (HeRO) graft placement using the newly established supraclavicular vascular access.

Intrastent HeROgraft deployment as a catheter-sparing procedure.

Current vascular access (VA) practice adopts arteriovenous fistulas (AVF) as first option for haemodialysis, relegating arteriovenous grafts (AVG) for patients with exhausted upper limb venous patrimony. The Hemodialysis Reliable Outflow graft (HeRO®) is a device assuring direct venous outflow to the right atrium, thus avoiding central venous obstructive disease. Its use together with early access grafts avoids the need for central venous catheters (CVC) bridging periods. We report the deployment of the HeRO device using a previous stentgraft as pathway for the placement of the outflow component, in a patient with no-option for further autogenous upper limb access. This technique spared the usual central vein's exit point for the HeRO graft and, using an early-access dialysis graft, allowed for next-day successful haemodialysis.

Efficacy of Hemodialysis Reliable Outflow Grafts and the Surfacer Catheter System for Central Venous Recanalization and Vascular Access Creation: A Single-Center 7-Year Experience

Efficacy of Hemodialysis Reliable Outflow Grafts and the Surfacer Catheter System for Central Venous Recanalization and Vascular Access Creation: A Single-Center 7-Year Experience

Management of concomitant central venous disease.

Symptomatic central venous disease (CVD) is a significant common problem in patients with end-stage renal disease given its adverse impact on hemodialysis (HD) vascular access (VA). The current mainstay management is percutaneous transluminal angioplasty (PTA) with or without stenting which is typically reserved for unsatisfactory angioplasty or more challenging lesions. Despite factors such as target vein diameters and lengths and vessel tortuosity that may determine the choice of bare-metal versus covered stents (CS), current scientific literature is pointing out the superiority of the latter one. Alternative management options such as hemodialysis reliable outflow (HeRO) graft showed favorable results in terms of high patency rates and fewer infections, however, complications such as a steal syndrome and, to a lesser extent, graft migration and separation are major concerns. The surgical reconstruction approaches such as bypass, patch venoplasty, or chest wall arteriovenous graft with or without endovascular interventions as a hybrid procedure are still viable options and may be considered. However, further long-term investigations are needed to highlight the comparative outcomes of these approaches. Open surgery might be an alternative before proceeding to more unfavorable approaches such as lower extremity vascular access (LEVA). The appropriate therapy should be selected based upon a patient-centered interdisciplinary discussion utilizing the locally available expertise in the area of VA creation and maintenance.

Successful Management of Recurrent Tunneled Dialysis Catheter Infections with the Hemodialysis Reliable Outflow Graft Device

The hemodialysis reliable outflow (HeRO) graft was designed for patients with failed arteriovenous accesses caused by an obstructed central venous outflow or patients who have exhausted all upper arm options. We describe a patient with severe stenosis of the superior vena cava (SVC) who experienced recurrent episodes of infection of permanent tunneled catheters, resulting in repeated hospitalizations. We successfully used the HeRO graft after angioplasty of the SVC. This indication for placing the HeRO graft has not been emphasized and mentioned previously in the literature. We also reviewed the literature regarding comparisons of this technique with other options.

Modified proximalization of arterial inflow using a hemodialysis reliable outflow graft in a patient with vascular access failure.

A 63-year-old man with end-stage renal disease and multiple failed vascular accesses (VAs) had been referred for creation of permanent dialysis access. He provided written informed consent for the report of his case details and imaging studies. His medical history included a failed kidney transplantation, aortic valve replacement, severe coronary artery disease requiring two coronary artery bypass grafts, and hypertension. A previous right groin and upper extremity VA had been complicated by chronic deep and central vein thrombosis, requiring stenting of the right innominate and superior vena cava (SVC) due to SVC syndrome.

HeRO Graft: Indications, Technique, Outcomes, and Secondary Intervention.

The Hemodialysis Reliable Outflow (HeRO) graft is a nontraditional, surgical, and endovascularly placed access that offers options in failing arteriovenous fistula/arteriovenous graft or catheter-dependent patients. The HeRO graft provides a unique option and is specifically referred to in the 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) vascular access update. The interventional radiologist has a role and opportunity to work collaboratively with surgeons in assisting with (1) the identification, selection, preparation for, and placement of HeRO grafts and (2) providing post-placement maintenance to ensure long-term patency.

Hemodialysis Reliable Outflow (HeRO) graft creation in upper extremities abandoned due to stent obstruction via recanalization and HeRO outflow component insertion across stent interstices.

The purpose of this study was to assess the feasibility and outcomes of recanalization and subsequent HeRO graft outflow component insertion across stent interstices in patients with an otherwise abandoned upper extremity. Over a 10-year period, 15 patients underwent central venous recanalization by interventional radiology across the interstices of one or more occluded stents for the purpose of subsequent HeRO graft creation. A tunneled central venous catheter was left across the stent and occlusions with tip in right atrium. On a later date, the catheter was used for rapid guidewire access for HeRO graft implantation in the OR by vascular surgery. Procedural and clinical outcomes were determined by retrospective review. Primary and secondary HeRO graft patency rates were estimated with the Kaplan-Meier technique. The technical success rates of recanalization across stent interstices was 100% (15/15). Between one and four overlapping stent walls were traversed. The technical success of the patients who underwent attempted HeRO graft implantation with outflow component traversing across stent interstices was 91% (11/12). No major complications were encountered with either recanalization or HeRO graft implantation. The primary and secondary HeRO patency rates at 12 months were 64% and 80%, respectively. HeRO graft insertion across stent interstices is feasible and can provide effective permanent AV access; thus, the presence of stents across the subclavian and brachiocephalic veins should not be considered a contraindication.

HeRO® graft: technical application and clinical experience in 73cases

Zunehmendes Alter, Komorbiditäten und die Dauer der chronischen Dialysepflichtigkeit erschweren die Anlage und den Erhalt eines funktionierenden Gefäßzugangs bei Patienten mit terminaler Niereninsuffizienz. Dabei steigt durch zentralvenöse Katheter und kardiologische bzw. onkologische Eingriffe das Risiko einer zentralen Stenose bzw. Okklusion. Die Implantation des Hemodialysis-Reliable-Outflow(HeRO®)-Grafts (Merit Medical Systems Inc., South Jordan, UT, USA) ist ein inzwischen etabliertes kombiniert chirurgisch/interventionelles Verfahren zur Wiederherstellung des stenosierten oder okkludierten venösen Abstroms. Hierdurch kann der Gefäßzugang an der oberen Extremität erhalten bleiben und die wichtige Gefäßressource der unteren Extremität geschont werden. In unserem Zentrum wurden seit 2013 insgesamt 73 Grafts erfolgreich mit steigendem Bedarf implantiert. Der operative Eingriff ist bei uns ein etabliertes und risikoarmes Verfahren geworden. Nach der Implantation ist bei akuter Thrombosierung jedoch 2‑ bis 3‑mal jährlich eine Reintervention erforderlich. Entsprechende Erfahrung vorausgesetzt, sind diese Revisionseingriffe technisch einfach durchzuführen. Bei vollständiger Okklusion der zentralvenösen Strombahn im Bereich der V. cava superior, die nicht durch den HeRO®-Graft passiert werden kann, ist ein Kombinationseingriff mit dem Surfacer®-Sytem (Inside-out-Verfahren) möglich und sinnvoll. Der HeRO®-Graft kann bei Bedarf an eine früh punktierbare Prothese angeschlossen werden. Hierdurch können passagere Dialysekatheter vollständig umgangen werden. Trotz steigender Zahl der HeRO®-Graft-Implantationen bleibt diese Option in unserem Zentrum ein Reserveverfahren. Die interventionellen Verfahren ohne Implantation von Fremdmaterial sollten zunächst ausgeschöpft und etablierte gefäßchirurgische Alternativen (wie beispielsweise der V.-jugularis-Anschluss) vorrangig durchgeführt werden.

Safe and effective HeRO graft placement: Technique and results.

Hemodialysis Reliable Outflow (HeRO) grafts are used when venous outflow is inadequate to support conventional access. These have been perceived as complex to implant and being associated with high risk. We have evolved a defined protocol for insertion that minimizes morbidity and maximizes efficiency. Our protocol includes staged intravenous access versus HeRO graft placement, reverse Trendelenburg positioning, subcutaneous access of the deep portion of the existing catheter, use of a stiff wire placed within the inferior vena cava, dilation of the tract to 8 mm, device lubrication, all insertion procedures directly visualized, and use of immediate access conduits with SuperHeRO connector. From 7/1/18 to 8/13/19, 55 HeRO grafts were placed at our institution following this protocol, average age 58 ± 15 (26-86) years (mean ± SD, range). 53 (96%) had had prior ipsilateral central access (13 by means of "inside out" 2 weeks prior) the other two had on-table access. Mean procedure time was 70 ± 26 (38-148) min. Excluding seven "complex" cases, procedure time for our first 20 cases using this protocol was 72 ± 29 min, while that of the last 28 was 62 ± 18 min (p < 0.05). One patient suffered acute CHF after unclamping; despite reclamping and ligation he died on POD 3 (mortality rate 2%). 71% were done as outpatients, and 47 of 53 evaluable patients (89%) had their grafts used within 36 h for dialysis. Only one patient (2%) has had an infection within 30 days (cellulitis). At a mean followup of 95 ± 105 (maximum 383) days, three additional patients have had graft infections requiring excision, for a total infection rate of 5/53 (9%). Our results suggest that HeRO graft placement can be performed with minimal morbidity and mortality on an outpatient basis. Short-term infection rates are low and 89% of patients have their grafts immediately accessed and are discharged without a catheter.

A comparison of stenting versus hemodialysis reliable outflow graft for hemodialysis patients with recurrent central venous obstructions

BackgroundCentral venous occlusive disease is a common cause of upper extremity arteriovenous access dysfunction in hemodialysis patients. When refractory to balloon angioplasty, the treatment options include central venous stenting and hemodialysis reliable outflow (HeRO; Merit Medical, South Jordan, Utah) graft. The purpose of the present study was to evaluate the outcomes of these options. MethodsA retrospective review was performed of patients who had undergone central venous stenting or HeRO placement for central venous obstruction from December 2008 to March 2018. The primary outcomes were the reintervention rates, patency, and mortality. ResultsA total of 75 hemodialysis patients were identified after failed balloon angioplasty for central venous obstruction. Of the 75 patients, 44 underwent central venous stenting comprising coverage of the subclavian vein (n = 27), innominate vein (n = 18), and/or superior vena cava (n = 5). Six stent patients later underwent HeRO placement. The stents used were stent grafts in 65% (Viabahn, n = 9; Fluency/Flair, n = 19; iCast, n = 2; and other, n = 1) and bare metal stents in 35% (Wall-stent, n = 6; Protégé, n = 1; Cobalt, n = 1; and other, n = 9). The remaining 31 patients underwent HeRO graft placement. The venous outflow component insertion sites were the internal jugular (n = 20), external jugular (n = 1), subclavian (n = 6), axillary (n = 2), and other (n = 2). The stent and HeRO groups were similar in the previous central venous intervention rates (median, 0.6 [interquartile range (IQR), 0-3.0]; vs median, 3.5 [IQR, 0-10.1] annually; P = .679). After the index procedure, no difference was found between the two groups in the frequency of dialysis circuit interventions annually (median, 2.0 [IQR, 0-6.0]; vs median, 2.0 [IQR, 0-7.0]; P = .291) nor central venous interventions (ie, angioplasty of the central veins or within the portion of the HeRO inside the central veins) annually (median, 2.0 [IQR, 0-4.1]; vs median, 0 [IQR, 0-2.4]; P = .419). The 1-year access circuit primary patency was 8.1% for stenting and 22.2% for HeRO (P = .109). The 2-year access circuit secondary patency was 40.0% for stenting and 52.4% for HeRO (P = .401). The all-cause mortality was similar at 1 year (3.7% vs 4.8%; P = .856) and 2 years (11.8% vs 23.5%; P = .368). ConclusionsCentral venous stenting and HeRO were shown to have similar rates of reintervention and patency. The results from the present study suggest that the multiple treatment options available for this problematic disease process can yield similar results when careful patient selection is applied.

Novel Reconstruction of Complex Central Venous Occlusion Using Supraclavicular Stent Graft in Hemodialysis Patients

Subclavian vein and brachiocephalic vein occlusions are challenging problems in dialysis patients with ipsilateral upper extremity (UE) vascular access or in need of one. HeRO grafts (Hemodialysis Reliable Outflow, Merit Medical Systems, Inc, South Jordan, UT) have been used to manage such occlusions but patients with chronic hypotension treated with HeRO graft may have threatened patency. We describe an alternative technique using a supraclavicular stent graft to reconstruct the venous outflow, evaluate outcomes of this procedure, and discuss its role in complex hemodialysis patients. From January 2019 to January 2020, we performed open surgical and endovascular dialysis access procedures in 297 patients. Eight patients (2.7%) with failing or failed access and subclavian and or brachiocephalic vein occlusion were treated with supraclavicular stent graft placement. Mean age was 52 years, ranging from 32 to 70. Five patients had failed access and were dialyzed using catheters (two femoral). Three patients with failing fistulas had severe arm edema. Two patients had recurrent HeRO graft thrombosis. We performed a retrospective review of these 8 patients and evaluated access patency and complications. Technical success and access function were 100% in all patients. One patient developed ischemic neuropathy and underwent proximalization of the arterial inflow with improvement. Already-existing fistulas were used for dialysis the day after the procedure and new grafts within 2-4weeks. Arm edema resolved within one week after the procedure. Median follow-up was 254.5days, range 24-408days, with primary patency rate of 87.5% and secondary patency rate of 100%. Only one patient has required reintervention. Postoperative evaluation with ultrasound has revealed patent stent graft in the area of the subcutaneous cervical tunnel over the clavicle. Supraclavicular stent graft placement to a central vein can be used successfully to reconstruct venous outflow in hemodialysis patients with complex central vein occlusions. A supraclavicular extra-anatomic path can be used safely and effectively to place new UE vascular access or salvage threatened access in this challenging patient population.

Use of the Surfacer® Inside-Out® Catheter Access System to Obtain Central Venous Access in Dialysis Patients With Thoracic Venous Obstructions: Single-Center Series.

Thoracic central venous obstruction (TCVO) is a common condition which can impact the ability to achieve central venous access (CVA) in patients on hemodialysis. The Surfacer® Inside-Out® Catheter Access System is designed to enable repeated right-side central venous access in patients with TCVO. We retrospectively analyzed medical records of 10 dialysis patients who presented with TCVO and underwent the Inside-Out procedure with the Surfacer System to obtain CVA between 2017 and 2020. Patient demographics, hemodialysis vascular access history, and procedural data were identified and analyzed. The mean patient age was 62.4 ± 19.6 years (25.9-89.1 years) with 7 of the 10 patients being male. Eight patients (80.0%) were diagnosed with chronic kidney disease with time on hemodialysis ranging from 3 to 13 years. The remaining 2 required CVA to treat acute-on-chronic kidney injury due to septic shock. Patients in our series had a mean of 2.8 ± 1.6 previous catheters placed prior to the Surfacer procedure. CVA was achieved in all 10 patients with 1 patient requiring a second attempt to achieve access due to the inability to initially traverse the iliac vein with the device, possibly due to a history of kidney transplantation. One multimorbid patient died shortly after the successful procedure, possibly due to cardiac decompensation. Mean total procedure time for the 7 patients having only dialysis catheter placement using the Surfacer device was 67.2 ± 19.1 minutes (49-103 minutes). The remaining 3 patients received a Hemodialysis Reliable Outflow (HeRO) graft in conjunction with the Inside-Out procedure. All vascular accesses functioned properly during the immediate time period following placement. No adverse events associated with the use of Surfacer device were encountered. Data presented from our patient series confirms the effectiveness of the Surfacer System to safely achieve CVA in dialysis patients with TCVOs with a history of multiple catheter placements.

Safe and Efficient HeRO Graft Placement

Hemodialysis Reliable Outflow (HeRO) grafts (Merit Medical, South Jordan, Utah) are used when venous outflow is inadequate to support a conventional access. These have been perceived as complex to implant and being associated with high infection and morbidity rates. Our results have been favorable, and during the past few years we have evolved a defined protocol for insertion that minimizes morbidity and maximizes efficiency. Our protocol includes staged intravenous access vs HeRO graft placement, reverse Trendelenburg positioning, subcutaneous access of the deep/clean portion of the existing catheter, use of a stiff wire placed within the inferior vena cava, dilation of the tract to 8 mm, device lubrication, direct visualization of all insertion procedures, and use of immediate access conduits with Super HeRO connector. From July 1, 2018, to August 13, 2019, there were 55 HeRO grafts placed at our institution following this protocol; male-female ratio was 3:2, and average age was 58 ± 15 years (range, 26-86 years); 75% were done on an outpatient basis. Median length of stay for the 14 inpatients was 1.5 (1-8) days. There were 53 patients (96%) who had prior ipsilateral central access (13 by means of “inside-out” 2 weeks earlier); the other 2 patients had on-table access. Mean procedure time was 70 ± 26 (38-148) minutes. Excluding six “complex” cases and one with a mechanical malfunction, procedure time for our first 20 cases using this protocol was 72 ± 29 minutes, whereas that of the last 28 was 62 ± 18 minutes (P < .05). One patient suffered acute congestive heart failure after unclamping; despite reclamping and ligation, he died on postoperative day 3 (mortality rate, 2%). Of 53 evaluable patients, 47 (89%) had their grafts used within 36 hours for dialysis access. Excluding the two patients, only one patient (2%) has had an infection within 30 days (cellulitis, resolved with antibiotics). At a mean follow-up of 95 ± 105 (maximum, 383) days, three additional patients have had graft infections requiring excision, all within the body of the graft without coupler involvement, for a total infection rate of 5 of 53 (9%). Our results suggest that HeRO graft placement can be performed with minimal morbidity and mortality on an outpatient basis. Short-term infection rates are low (2%), which we ascribe to retrieval of the existing catheter deep to the cuff, and 89% of patients have their grafts immediately accessed and are discharged without a catheter.

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula