Multi-center Experience of 164 Consecutive Hemodialysis Reliable Outflow [HeRO] Graft Implants for Hemodialysis Treatment

Alternatives for exhausted dialysis access

Hemodialysis (HD) access failure is a frequent problem encountered by vascular surgeons. As treatment of end-stage renal disease improves and patients live longer on HD, eventual exhaustion of traditional upper extremity HD access is common. Efforts to preserve and maintain these accesses are essential. However, when they fail, alternative surgical access options should be pursued prior to destination-tunneled dialysis catheters. Hemodialysis Reliable Outflow grafts as well as various configurations of lower extremity arteriovenous fistulae and grafts can be utilized. For most alternative HD access options, there is a paucity of data for long-term patency, cost, and risk of infectious or ischemic complications compared to traditional options. However, smaller studies examining Hemodialysis Reliable Outflow grafts, femoral vein transposition, and lower extremity grafts show acceptable safety and efficacy. Depending on the cause of traditional access failure and patient-specific anatomic constraints, we recommend a systematic approach to alternative access creation, with destination-tunneled dialysis catheters reserved as a last resort. The most common cause of HD access failure is venous outflow obstruction. As such, we have structured this manuscript around a meta-analysis of retrospective studies describing nontraditional access options that can be utilized with escalating degrees of central venous stenosis or occlusion.

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.

HeRO graft-The results of the cologne single center study

OBJECTIVE

The HeRO graft is a technique for vascular access in patients with limited treatment options; however, the published results with the HeRO graft are diverging. We therefore conducted a single-center study.

METHODS

Patient records between July 2014 and February 2020 from Vascular Access Unit of the Department of Vascular and Endovascular Surgery of University Clinic of Cologne (Germany) were reviewed. Retrospective data was analysed from patients with a HeRo graft (n = 18).

RESULTS

Eighteen patients were enrolled in the study. The mean age of the patients was 62.8 ± 17.24 years. During the follow-up period, no patients died from complications related to the HeRO graft. Each patient had a mean of 1.94 concomitant diseases. The primary patency rates of the HeRO graft at 3, 6, 12, 18, and 24 months were 61.1%, 50%, 16.7%, 11.1%, and 5.6%, respectively. The secondary patency rates at the same time intervals were 77.8%, 72.8%, 55.6% 55.6%, and 55.6%, respectively. There were 44 re-operations per year, or 2.4 operations per patient. The main cause of acute complications was acute graft occlusions after HERO graft implantation. An infection after the graft implantation occurred in five (27.7%) patients, leading to graft explanation in 2 cases.

CONCLUSION

The use of the HERO graft is a valuable alternative method for providing a durable dialysis access in patients with limited access options. The secondary patency and survival are good with a low infection rate.

A systematic review of right atrial bypass grafting in the management of central venous occlusive disease in patients undergoing hemodialysis

INTRODUCTION

Central venous occlusive disease (CVOD) is a complication that can occur in patients with end-stage renal disease who are receiving hemodialysis. When CVOD develops, patients often require multiple re-interventions to maintain their dialysis access. CVOD can be treated by various strategies such as balloon angioplasty, stenting, lower limb or extra-anatomical grafts, hybrid grafts or surgical bypasses such as right atrial (RA). In this systematic review, we aim to evaluate the indications, technical aspects, and outcomes after RA bypass grafting for the treatment of CVOD in hemodialysis patients.

METHODS

A systematic and comprehensive literature search was conducted using various electronic databases. We included articles that reported described and reported outcomes of RA bypass grafting for the treatment of CVOD in hemodialysis patients. A narrative review of the indications and technical aspects of RA bypass grafting was performed. We also pooled and reported the primary patency, secondary patency, postoperative complications, and 30-day mortality of RA bypass grafting.

RESULTS

A total of 21 studies with 55 patients who underwent RA bypass grafting were included in our systematic review. Follow-up period ranged from 0.5 to 84 months. The mean pooled primary patency and secondary patency of RA bypass grafting were 8.1 ± 4.9 and 21.7 ± 20.1 months, respectively. The incidence of early postoperative complications such as surgical site infection, bleeding, and access thrombosis was 0%, 4%, and 4%, respectively. The overall 30-day mortality was 4%.

CONCLUSIONS

This systematic review summarizes the patient characteristics, technical features and outcomes of RA bypass grafting in the treatment of hemodialysis-related CVOD. RA bypass grafting may be a viable last-resort option when less invasive or conventional treatment options have been exhausted.

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.

Use of Surfacer, an inside-out device, in tandem with HeRO graft for creation of vascular access: Case report of three patients with 18-months follow up

The Surfacer Inside-Out Access Catheter System (Surfacer) is a novel approach to restore access in total central vein occlusion (TCVO). We report a series of three cases, with mean 18-months follow up, in our institution where this technique was safely and effectively used in tandem with Hemodialysis Reliable Outflow (HeRO) graft for creation of upper limb vascular access in patients with TCVO. Although there have been reports describing the simultaneous combination of Surfacer and HeRO graft, to our knowledge, this is the first time where the outcomes with 18-months mean follow-up are reported. All three patients had failed prior conventional attempts at TCVO crossing and had exhausted most conventional upper limb vascular access methods. The above technique yielded a 100% technical success rate with mean operative time of 140 min. Cannulation rate was 100% with all undergoing successful early cannulation by post-operative day 3. Mean primary patency of 199 days was achieved. Average intervention rate of 1.2 a year was required to maintain patency. The Surfacer device used together with HeRO graft is a feasible technique to avoid femoral catheter in patients where conventional attempts to cross the TCVO have failed.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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: technische Anwendung und eigene klinische Erfahrung in 73 Fällen

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.

Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet

OBJECTIVE

Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy.

METHODS

We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection.

RESULTS

During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months.

CONCLUSIONS

Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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 2-4 weeks. Arm edema resolved within one week after the procedure. Median follow-up was 254.5 days, range 24-408 days, 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.

CONCLUSIONS

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.

Endovascular treatment of type 3 and 4 thoracic central vein obstruction in hemodialysis patients

OBJECTIVE

Thoracic central vein (TCV) obstruction (TCVO) in the presence of upper extremity (UE) hemodialysis access can present as superior vena cava syndrome (SVCS) and cause vascular access dysfunction and failure. We report the techniques and results of endorevascularization of TCVO in hemodialysis patients, which allowed for long-term functioning vascular access in the UE.

METHODS

From June 2009 to February 2020, 45 hemodialysis patients underwent TCV endorevascularization. The indications for surgery were TCVO or SVCS that threatened the function of a preexisting upper arm access or contraindicated placement of a new upper arm access. Conventional endovascular techniques were used when feasible. Patients with unfavorable anatomy were treated using a transseptal needle to cross difficult intrathoracic stenosis and occlusions or to facilitate an inside-out central venous access technique. The reestablishment of venous outflow was accomplished with angioplasty, stenting, and/or placement of HeRO conduits. Successful revascularization was followed by hemodialysis access revision or a new UE access placement. We recorded the risk factors and procedural outcomes, patency rates, complications, and mortality.

RESULTS

The mean age was 53 ± 16.3 years, and 51% were women. The most common risk factors were diabetes mellitus (64.2%) and hypertension (56%). Twenty-five patients (55.5%) had symptoms of SVCS. These symptoms resolved after the TCV procedure in all cases. Crossing of the TCV lesion was successful using a conventional catheter and wire in 26 cases (57.8%) and transseptal needle in 17 cases (37.8%), including 12 using an inside-out central venous access technique. Treatment of the TCV lesion included a HeRO conduit in 20 cases (44.4%), stenting in 17 (37.7%), and transluminal balloon angioplasty alone in 7 (15.5%). Other veins were treated in 33 cases (73.3%). The overall technical success rate was 95.5%. Two intraoperative complications occurred, including one case of severe hypotension and one of fatal cardiac tamponade. Of the 16 patients with preexisting UE access, its function was preserved in all 16 (100%). In 24 of 27 patients (85.7%), new arm access was successfully created after the TCV procedure. The overall clinical success rate was 88.9%. The average follow-up was 663.4 days (median, 507 days; range, 0-2679 days). During follow-up, 26 patients had undergone 90 procedures to maintain access function, 21 had undergone repeat endovascular interventions, and 17 had undergone open procedures. Eight patients (17.8%) had developed infection, five involving HeRO conduits that required excision with loss of access. During the follow-up period, 14 patients (31%) had died of unrelated causes, and 34 patients (75.5%) maintained functional access.

CONCLUSIONS

The results of the present study have shown that endorevascularization of TCVO reconstruction is effective in maintaining function or allowing the creation of UE hemodialysis access, with acceptable complication rates.

Challenges and novel therapies for vascular access in haemodialysis

Advances in standards of care have extended the life expectancy of patients with kidney failure. However, options for chronic vascular access for haemodialysis - an essential part of kidney replacement therapy - have remained unchanged for decades. The high morbidity and mortality associated with current vascular access complications highlights an unmet clinical need for novel techniques in vascular access and is driving innovation in vascular access care. The development of devices, biological approaches and novel access techniques has led to new approaches to controlling fistula geometry and manipulating the underlying cellular and molecular pathways of the vascular endothelium, and influencing fistula maturation and formation through the use of external mechanical methods. Innovations in arteriovenous graft materials range from small modifications to the graft lumen to the creation of completely novel bioengineered grafts. Steps have even been taken to create new devices for the treatment of patients with central vein stenosis. However, these emerging therapies face difficult hurdles, and truly creative approaches to vascular access need resources that include well-designed clinical trials, frequent interaction with regulators, interventionalist education and sufficient funding. In addition, the heterogeneity of patients with kidney failure suggests it is unlikely that a 'one-size-fits-all' approach for effective vascular access will be feasible in the current environment.

Novel Approaches to Arteriovenous Access Creation, Maturation, Suitability, and Durability for Dialysis

Since the arteriovenous fistula (AVF) was first conceived over 50 years ago, the goal to create a vascular conduit with predictable and reproducible maturation and durability continues to elude caregivers. Recently, however, advances in the understanding of vascular biology and new technologies now provides us with some optimism; we are moving toward a viable solution. A quickly maturing, sustainable, and durable arteriovenous access may soon be attainable. This review will discuss these advances. There are novel approaches to AVF creation and devices to enhance maturation, advances in arteriovenous graft material(s), and devices to safely prolong the use of tunneled dialysis catheters. Although hemodialysis (HD) access remains a complex problem, these innovations may lead the way to optimizing the care and the quality of life of those patients who have no choice but to proceed with HD.

Hemodialysis Reliable Outflow graft: A valid option in patients with central venous stenosis

INTRODUCTION

Central venous stenosis can be the main obstacle to the creation of an autologous vascular access in the upper limbs. The Hemodialysis Reliable Outflow graft was developed to provide an upper limb vascular access option to such patients, avoiding alternative, less advantageous options, such as lower limb vascular accesses or central venous catheters. Its advantages include catheter avoidance and, in case of lower limbs accesses, reduction of the ischemic risk and iliac vein thrombosis, potentially compromising a future kidney transplant.

PATIENTS AND METHODS

Revision of the clinical files of the four patients who were placed a Hemodialysis Reliable Outflow device in our Center, including demographic variables, implantation technique characteristics, surgical complications, episodes of infection and thrombosis of the access, and need to place a transitory central venous catheter to undergo hemodialysis treatment.

RESULTS

Four Hemodialysis Reliable Outflow grafts were placed, which resulted in a significant improvement in the dialysis efficacy in all patients, with a median raise in the Kt/V of 36.7%. Two cases needed thrombectomy, one of which was unsuccessful. The actual time of patency varies between 3 and 28 months.

CONCLUSION

Our experience with the Hemodialysis Reliable Outflow device showed that it was a safe option for patients with central venous stenosis and was associated with good clinical and analytic outcomes.

Early cannulation of the Hemodialysis Reliable Outflow graft

OBJECTIVE

In complex dialysis patients, central venous stenosis may preclude additional upper extremity access options. The Hemodialysis Reliable Outflow graft (Merit Medical Systems, Inc.) can bypass this stenosis providing patients with an additional upper extremity long-term access option. We report our experience with early-cannulation Hemodialysis Reliable Outflow grafts and compare them to traditional Hemodialysis Reliable Outflow grafts.

METHODS

We retrospectively reviewed all patients undergoing Hemodialysis Reliable Outflow graft placement from 1 January 2013 through 15 August 2017 at our institution and compared those undergoing placement of traditional Hemodialysis Reliable Outflow grafts and simultaneous tunneled dialysis catheter insertion to those undergoing Hemodialysis Reliable Outflow graft placement using an early-cannulation Hemodialysis Reliable Outflow graft without a tunneled dialysis catheter.

RESULTS

A total of 88 patients had 98 Hemodialysis Reliable Outflow grafts inserted throughout this time period. Of these, 61 (62%) were early-cannulation Hemodialysis Reliable Outflow grafts, while 37 (38%) were traditional Hemodialysis Reliable Outflow grafts. Primary, primary-assisted, and secondary patency rates at 1 year were higher for the traditional Hemodialysis Reliable Outflow graft cohort (53.1% vs 25.2%, p < 0.01; 70.1% vs 30.5%, p < 0.01; and 80.4% vs 55.4%, p = 0.07, respectively). There was no difference in the rate of postoperative hematoma, seroma, pseudoaneurysm formation, steal syndrome, or overall graft thrombosis between the two cohorts. Early-cannulation Hemodialysis Reliable Outflow grafts required earlier reintervention for thrombosis and earlier reintervention for any cause when compared to traditional Hemodialysis Reliable Outflow grafts (146 ± 184 days vs 417 ± 272 days, p < 0.01, and 123 ± 169 days vs 401 ± 311 days, p < 0.01, respectively).

CONCLUSION

In complex dialysis patients, early-cannulation Hemodialysis Reliable Outflow grafts have significantly lower 1-year primary and primary-assisted patency rates and require earlier reintervention to maintain this patency compared to traditional Hemodialysis Reliable Outflow grafts.

Transposition of external jugular to proximal internal jugular vein for relief of venous thoracic outlet syndrome and maintenance of arteriovenous fistula access for chronic hemodialysis: A new approach

We are reporting a case of venous thoracic outlet syndrome with recurrent subclavian vein thrombosis in the setting of an ipsilateral brachiocephalic arteriovenous fistula for hemodialysis that was malfunctioning due to the central vein obstruction. The patient also had a concomitant external jugular vein origin stenosis. Given her body habitus and aversion to recovery after traditional first rib resection, we elected for an alternative treatment with an external jugular vein to internal jugular vein transposition with balloon angioplasty of the stenosed external jugular origin segment. The goal of this was to provide simultaneous relief of her outlet obstruction symptoms and salvage her dialysis access with a less invasive technique.

Options for end stage vascular access: Translumbar catheter, arterial-arterial access or right atrial graft?

Background:

Running out of vascular access for dialysis is thankfully rare, but despite this, most units will have a number of patients with few options and in a precarious state. The increasing longevity of dialysis patients portends more patients will reach minimal access options. End stage vascular access is poorly defined but classification may enable assessment and comparison of treatment options. Three options for patients with end stage access are a central venous catheter through a translumbar or transhepatic route, arterial-arterial prosthetic loop or a right atrial graft.

Aims:

The aims of this study are to provide a structured review of evidence for these procedures to allow application and guide practice for patients with end stage vascular access.

Methods:

A standardised search of published literature was performed of relevant studies. In addition, the references cited in those papers were assessed for any further available articles. All study types were included and reviewed by two authors independently. Primary outcomes were patient survival and secondary patency rate at 3 and 12 months. Secondary outcomes were long-term patency rates, mean time to cannulation and complications such as access dysfunction, thrombosis and infection.

Summary:

Based on the available evidence, it would appear that arterial-arterial prosthetic loop is a definitive option for maintaining dialysis access in patients with no more arteriovenous access options. Translumbar and transhepatic dialysis catheters may offer short- and medium-term options and right atrial grafts may also be suitable as an option where arterial-arterial prosthetic loop is unsuitable.

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.

Maintaining lower limb access with the HeRO device

Central venous catheters (CVC) remain a mainstay of vascular access particularly for incident patients,
but lead to central vein stenosis (CVS) in up to 1 in 6 patents. This often leads to establishing dialysis access in the groin which in turn may result in development of CVS in the lower body, although this is poorly reported. The HeRO device was designed to address CVS by bypassing the stenosed veins with a nitinol-reinforced silicone tube into the right atrium, which acts as an outflow conduit attached to an arterial inflow. The efficacy and safety of the HeRO device in the upper limb is well established, but there is no data on its use in the lower limb. We describe 2 cases of HeRO in the lower limb, one primary and one secondary, which remain in use. Lower limb HeRO is feasible in the lower limb and can work well either as de novo (to achieve vascular access) or as a salvage procedure (to maintain vascular access).

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

The United Kingdom and Ireland experience of the Haemodialysis Reliable Outflow graft for vascular access

Objectives:

To describe the UK and Ireland experience of the Haemodialysis Reliable Outflow graft in complex vascular access.

Design:

Observational, multi-centre case series.

Methods:

Data from any patient undergoing Haemodialysis Reliable Outflow graft were collected from eight UK and one Irish centre. Any Haemodialysis Reliable Outflow procedure between July 2013 and May 2016 was included. Demographics, primary and secondary patency rates, and complications were analysed.

Results:

A total of 52 patients underwent Haemodialysis Reliable Outflow graft insertion. Median age was 55 (20–86) years, 24 (46%) were male and 66% were Caucasian. Median follow-up was 290 (10–966) days and patient survival was 41/52 (79%). In total, 48 procedures were in the upper limb with 39 using the brachial artery as inflow (75%). The internal jugular vein and subclavian vein were most frequently used as access for outflow insertion. Primary patency rates at 6, 12, and 24 months were 51.2% (95% confidence interval, 38.8%–67.4%), 40.9% (95% confidence interval, 28.7%–58.2%), and 33.4% (95% confidence interval, 21.3%–52.5%), respectively. Secondary patency rates at 6, 12, and 24 months were 84.8% (95% confidence interval, 75%–95.9%), 76.5% (95% confidence interval, 64.5%–90.6%), and 70.6% (95% confidence interval, 56%–88.9%), respectively. There were 65 surgical and 49 radiological interventions resulting in 2.30 interventions per year to retain patency. Complications included four infections and two episodes of steal syndrome.

Conclusion:

The Haemodialysis Reliable Outflow graft provides acceptable 12-month secondary patency rates and acceptable complication rates in a UK and Ireland multi-centre series of complex access patients. Haemodialysis Reliable Outflow should be considered in patients with central pathology as a potential alternative to lower limb grafts and long-term central venous catheters.

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

Introduction

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.

Methods

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.

Results

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.

Conclusions

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.

Treatment of central venous in-stent restenosis with repeat stent deployment in hemodialysis patients

Purpose

To report patency rates for stent deployment for treatment of in-stent stenosis of the central veins of the chest in hemodialysis patients.

Materials and Methods

A retrospective analysis was performed on 29 patients who underwent 35 secondary percutaneous transluminal stent (PTS) deployments for in-stent stenosis within the central veins that were refractory to angioplasty and ipsilateral to a functioning hemodialysis access (in-stent PTS group). For comparison, patency data were acquired for 47 patients who underwent 78 successful percutaneous transluminal angioplasty (PTA) procedures for in-stent stenosis (in-stent PTA group) and 55 patients who underwent 55 stent deployments within native central vein stenosis refractory to angioplasty (native vein PTS group).

Results

The 3-, 6-, and 12-month primary lesion patency for the in-stent PTS group was 73%, 57%, and 32%, respectively. The 3-, 6-, and 12-month primary patency for the in-stent PTA group was 70%, 38%, and 17% and for the native vein PTS group was 78%, 57%, and 26%, which were similar to the in-stent PTS group (p = 0.20 and 0.41, respectively). The 3-, 6-, and 12-month secondary access patency was 91%, 73%, and 65% for the in-stent PTS group. Sub-analysis of the in-stent PTS group revealed no difference in primary (p = 0.93) or secondary patency rates (p = 0.27) of bare metal stents (n = 23) compared with stent grafts (n = 12).

Conclusions

Stent deployment for central vein in-stent stenosis refractory to angioplasty was associated with reasonable patency rates, which were similar to in-stent PTA and native vein PTS.

Placement of Upper Extremity Arteriovenous Access in Patients with Central Venous Occlusions: A Novel Technique

BACKGROUND

Central venous occlusion is a common occurrence in patients with end-stage renal disease. Placement of upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins is often not an option. Avoidance of lower extremity vascular access can decrease morbidity and infection.

METHODS

The central venous lesions were crossed centrally via femoral access. The wire was retrieved in the neck extravascularly. A Hemodialysis Reliable Outflow catheter was then placed in the right atrium and completed with an arterial anastomosis.

RESULTS

We describe a novel technique for placing upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins. This technique was utilized in 3 patients. The technical success was 100%.

CONCLUSIONS

The placement of upper extremity arteriovenous access in patients with central venous occlusions is technically feasible.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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 21.2 months (min, 0.0; max, 85.3 months) for thigh grafts and 6.7 months (min, 0.0; max, 56.3 months) 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 6 months, 1 year, and 3 years 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 6 months, 1 year, and 3 years were 75%, 66%, and 54% for the thigh grafts and 41%, 30%, and 10% for the HeRO grafts. Point estimates of secondary patency at 6 months, 1 year, and 3 years 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).

CONCLUSIONS

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.

Arteriovenous Access: Infection, Neuropathy, and Other Complications

Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.

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

OBJECTIVE

This 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.

METHODS

A 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.

RESULTS

For 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.

CONCLUSIONS

The 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.

Lower Extremity Permanent Dialysis Vascular Access

Hemodialysis remains the most commonly used RRT option around the world. Technological advances, superior access to care, and better quality of care have led to overall improvement in survival of patients on long-term hemodialysis. Maintaining a functioning upper extremity vascular access for a prolonged duration continues to remain a challenge for dialysis providers. Frequently encountered difficulties in clinical practice include (1) a high incidence of central venous catheter-related central vein stenosis and (2) limited options for creating a functioning upper extremity permanent arteriovenous access. Lack of surgical skills, fear of complications, and limited involvement of the treating nephrologists in the decision-making process are some of the reasons why lower extremity permanent dialysis access remains an infrequently used option. Similar to upper extremity vascular access options, lower extremity arteriovenous fistula remains a preferred access over arteriovenous synthetic graft. The use of femoral tunneled catheter as a long-term access should be avoided as far as possible, especially with the availability of newer graft-catheter hybrid devices. Our review provides a summary of clinical evidence published in surgical, radiology, and nephrology literature highlighting the pros and cons of different types of lower extremity permanent dialysis access.

From ZeRO to HeRO: Saving lives one HeRO at a time

INTRODUCTION

This case report intends to highlight the Haemodialysis Reliable Outflow (HeRO) graft as a potential long term option for ongoing dialysis in patients with central venous stenosis.

PRESENTATION OF CASE

A 55year old patient, who developed end stage renal failure (ESRF) after chemotherapy treatment for breast cancer, presented at the limit of her dialysis access after a 15year haemodialysis history causing central vein stenosis. The patient was initially started on peritoneal dialysis but after repeated peritonitis was switched to haemodialysis. Over fifteen years of haemodialysis the patient had fistulae created in all four limbs. She had multiple tunnelled neck lines and developed an occluded left brachiocephalic vein and stenosed superior vena cava. Catheter dialysis via the right internal jugular vein was attempted but proved increasingly problematic due to poor clearances and frequent catheter changes. A further attempt was made to treat with peritoneal dialysis, but again, this was unsuccessful. As the patient had two failed attempts at peritoneal dialysis, had exhausted all her peripheral access options, and was having problematic catheter dialysis, she was offered the option of the HeRO graft as a 'last resort'.

DISCUSSION

The HeRO graft is a fully subcutaneous vascular access system that bypasses the central venous system providing haemodialysis access for patients with central venous stenosis. It consists of an arterial graft component and a venous outflow component, which are connected via a titanium connector. The central vein stenosis/occlusion is stented with insertion of the graft in to the right atrium, which is then secured to the arterial component for needling. So that successful dialysis could be completed as soon as possible post-operatively, the HeRO graft, in this instance, was combined with an immediate needling graft (Acuseal). This allowed the patient to receive successful dialysis within hours of completing the procedure.

CONCLUSION

This patient had reached the end of her haemodialysis life with no other options available. She was treated successfully with the HeRO graft, which at two months was patent and problem free. The patient had been able to return to work for the first time in 15 months. Utilising the HeRO graft in this way may provide new, potentially long term, options for safe and effective dialysis in patients with central venous stenosis.

HeRO graft versus lower extremity grafts in hemodialysis patients with long standing renal failure

BACKGROUND

The role of the HeRO graft in central venous pathology has been defined in the literature and clinically. There have been two publications or abstracts that have compared the patency rates and outcomes of this graft to the lower extremity graft.

AIM

The outcomes of both publications leads to an algorithm suggested by the author in determining which procedure should be used for specific patients.

METHODS

Both papers trend to show that lower extremity grafts have improved patency rates when compared to the HeRO device in the upper extremity.

DISCUSSION

The author will use these data to demonstrate that in younger patients and in patients with low morbidity and mortality, salvaging the upper extremity area for access may show that the HeRO device provides benefit for these patients.

The Use of HeRo Catheter in Catheter-dependent Dialysis Patients with Superior Vena Cava Occlusion

Objectives

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.

Methods

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.

Results

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%.

Conclusions

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.

Multidisciplinary team approach to end-stage dialysis access patients

BACKGROUND

The 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.

METHODS

The 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.

RESULTS

A 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.

CONCLUSIONS

In 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.

Experience with chest wall arteriovenous grafts in hemodialysis patients

BACKGROUND

Maintaining long-term hemodialysis access in end-stage renal disease patients presents a serious challenge to surgeons. Over time, patients' remaining access sites diminish while complications and comorbidities simultaneously multiply; often resulting in the use of permanent tunneled catheters, which have a well-known high rate of complications and short-term usefulness. In this study, we report the results of a dialysis graft based on the axillary artery and ipsilateral axillary vein and tunneled in the subcutaneous tissues of the chest.

METHODS

We identified patients who had a chest wall arteriovenous graft (CWAVG) placed at our institution between May 2007 and December 2012. After institutional review board approval, the patients were retrospectively and then prospectively identified and followed for 2 years to document the performance, required maintenance, and complications of the graft.

RESULTS

Sixty-seven grafts in 67 patients were reviewed, representing 0.56% of our 1,192 total dialysis access creations during the study period. The average patient was 55-year-old with an average history of 3.97 explicitly documented prior accesses. Sixty interventions were performed postoperatively including 32 for thrombosis and 28 for venous stenosis. Six documented graft infections occurred (9%). Three minor wound complications occurred, but the graft was preserved. Notably, no patient developed symptoms of steal syndrome. The primary and secondary patency rates at 1 and 2 years were 69.5% and 36.9% and 81.6% and 57.6%, respectively. Twenty-three of the 67 patients died in the 2-year follow-up period (34%).

CONCLUSIONS

CWAVGs are useful and appropriate for patients with difficult upper extremity access. The patency rates for this "exotic" procedure are at least equivalent to other upper extremity grafts. The infection rate is lower than that for femoral grafts or tunneled catheters, and there is no risk of steal syndrome. CWAVGs can even be considered for primary use in patients who have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome.

Avoiding the use of a femoral bridging catheter using a two-stage Hemodialysis Reliable Outflow (HeRO) graft implantation technique

PURPOSE

To evaluate a two-stage Hemodialysis Reliable Outflow (HeRO) implantation technique that avoids the use of a femoral bridging catheter versus the conventional one-stage technique requiring a bridging catheter in selected patients.

METHODS

A retrospective review was performed on 20 end-stage renal disease patients with an internal jugular vein (IJV) catheter selected for two-stage HeRO implantation at our institution between January 2010 and March 2013. The arterial graft component (AGC) was implanted without anastomosing it to the target artery (first stage). After AGC incorporation, the venous outflow component was inserted (second stage). The preexisting IJV catheter was maintained for hemodialysis access during the interstage period. Patient characteristics, patency using Kaplan-Meier method and infection rates were analyzed.

RESULTS

A total of 17 patients with a mean age of 59 years (70.6% women) completed the two-stage procedure. During the interstage period (mean 12 weeks, range 4-22 weeks), no graft- or surgery-related infection occurred. The need of a femoral bridging catheter was avoided by utilizing the preexisting IJV dialysis catheter. The accumulated HeRO days were 3,916 days with a mean follow-up of 7.7 months (range 1-22.6 months). The HeRO-related infection rate was 0.3/1,000 days. The primary assisted and secondary patency rates at 6 months were 69% and 82%, respectively, which were similar to those of arteriovenous grafts. Staging conferred immediate vascular accessibility.

CONCLUSIONS

Avoiding the use of a femoral bridging catheter using the two-stage technique may lower infection rate, with comparable primary assisted and secondary patency to arteriovenous grafts and added benefit of immediate cannulatability in this subset of patients.

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

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

The end stage of dialysis access: femoral graft or HeRO vascular access device

BACKGROUND

Maintaining and establishing vascular access in end-stage renal disease (ESRD) patients is complicated when they are poor candidates for traditional upper extremity access. Our objective was to compare our experience with 2 alternative dialysis accesses, the femoral arteriovenous graft (fAVG) and the Hemodialysis Reliable Outflow (HeRO), in patients with limited remaining options.

METHODS

A single institution, retrospective review of ESRD patients with fAVG or HeRO placed between May 2009 and February 2013 was performed. Adult patients were selected by reviewing all arteriovenous grafts placed at a single institution. Patient demographics, medical history, access characteristics, and outcomes were recorded from both institutional and dialysis center databases. Data were evaluated using Fisher's exact test, unpaired t-test for continuous variables, log-rank test, and univariate analysis.

RESULTS

A total of 56 accesses in 43 unique patients met these criteria: 35 fAVG and 21 HeRO; with 1 HeRO patient lost immediately to follow-up. Clinical variables were similar except the HeRO group had more diabetic patients (60% HeRO, 22.9% fAVG; P = 0.01). The average number of years on hemodialysis was 7.0 ± 1.0 for fAVG and 5.7 ± 0.9 for HeRO (P = 0.41). Primary patency was 40.5%, 18.7%, and 14.9% for fAVG and 29.0%, 29.0%, and 0% for HeRO at 6 months, 12 months, and 2 years (P = 0.67), respectively. Assisted primary patency was also similar, with 43.8%, 29.4%, and 13.8% for fAVG and 34.8%, 34.8%, and 17.4% for HeRO at 6 months, 12 months, and 2 years (P = 0.81), respectively. Secondary patency was 62.6%, 50.6%, 19.3% for fAVG and 68.0%, 53.5%, 38.3% for HeRO at 6 months, 12 months, and 2 years (P = 0.69), respectively. Average number of interventions to maintain patency for fAVG was 1.1 ± 1.47 and 1.65 ± 2.52 for HeRO (P = 0.35). Infectious complications occurred in 29% of fAVG and 15% of HeRO (P = 0.33).

CONCLUSIONS

Patients who received either fAVG or HeRO experience poor access patency. ESRD patients who receive either of these procedures appear to be at the end stage of available access options.

Arteriovenous fistula salvage utilizing a hybrid vascular graft

INTRODUCTION

Loss of arteriovenous fistula as access for hemodialysis leads to significant morbidity and increased mortality risk.

METHODS

Maintenance of this access is of paramount importance and we describe a case of a patient with a functioning radiocephalic fistula with associated arm swelling due to poor narrow caliber venous drainage above the elbow but with normal central veins.

RESULTS

A hybrid vascular graft was anastomosed to the upper extent of the fistula and the nitonol stent section introduced into the patent axillary vein.

CONCLUSION

The described method led to resolution of symptoms and arm swelling. The described method allowed the continued use of a mature fistula.