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

Abstract

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

A Review on the Hemodialysis Reliable Outflow (HeRO) Graft for Haemodialysis Vascular Access

“…In addition the HeRO is a long device with a 5 mm internal diameter outflow which is more likely to limit flow be less prone to steal than larger conduits. Despite, this Wallace et al 9 did show a high rate of steal syndrome in their cohort of patients (22%). This can be explained by their small number of patients (n ¼ 4) who all had severe pre-existing arterial disease and required graft removal.…”

Lower Extremity Permanent Dialysis Vascular Access

“…The infectious complication in the LE-AVG group was higher compared with that in the HeRO group (29% versus 15%, respectively). The incidence of ischemia steal syndrome has also been reported to be high with the HeRO device (37).…”

New Method of Forced Implantation of Permanent Catheters for Hemodialysis into Critically Stenosed or Occluded Central Veins

“…Our method is somehow reintroduction of historical technique developed in 60ties of the last century by Charles Dotter, named "The permanent catheter placed in central veins and vascular PTFE graft anastomosed with brachial artery, seems to provide a vital option for these specific group of patients and our method can simplify the entire procedure of implantation (22).…”