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Early use conversion of the HeRO dialysis graft

Open ArchivePublished:April 18, 2011DOI:https://doi.org/10.1016/j.jvs.2011.02.018
      Although more challenging to place, the HeRO device (Hemosphere Inc, Eden Prairie, Minn) provides the dialysis access-challenged patient the opportunity to have an upper extremity graft rather than being dependent on a catheter or requiring a lower extremity access. A major difficulty with the HeRO is the need for a concomitant dialysis catheter until the graft matures. This has been associated with a large number of bacteremia episodes. Currently available early-access grafts have patency rates similar to standard polytetrafluoroethylene. We have modified the HeRO insertion technique to combine its attributes with those of an early-use graft. In the five patients presented in this report, we confirm that this new technique can give the patient a graft that is functional ≤72 hours and obviate the need for a concomitant catheter. This results in an infection-free access over the follow-up period.
      For dialysis access-challenged patients, the HeRO graft (Hemosphere Inc, Eden Prairie, Minn) has been shown to have lower infection rates, improved patency rates, and improved adequacy of dialysis compared with tunneled catheters.
      • Katzman H.E.
      • McLafferty R.B.
      • Ross J.R.
      • Glickman M.H.
      • Peden E.K.
      • Lawson J.H.
      Initial experience and outcome of a new hemodialysis access device for catheter-dependent patients.
      One report suggests they are durable.
      • Nassar G.M.
      Long-term performance of the hemodialysis reliable outflow (HeRO) device: the 56-month follow-up of the first clinical trial patient.
      Most patients receive this device due to a central venous stenosis that precludes use of an arteriovenous graft or native fistula. The options left for the patient are a tunneled catheter in the upper torso or access involving the lower extremities.
      The sentinel article by Katzman et al
      • Katzman H.E.
      • McLafferty R.B.
      • Ross J.R.
      • Glickman M.H.
      • Peden E.K.
      • Lawson J.H.
      Initial experience and outcome of a new hemodialysis access device for catheter-dependent patients.
      describes the placement technique. The main complication they encountered in 36 patients was bacteremia, which was most likely due to a concomitant tunneled catheter that was used until the HeRO device was matured. In their discussion, the authors recommend “cannulating the HeRO device as soon as possible and remove the bridging tunneled dialysis catheter.”
      Early-access dialysis grafts have been shown to have similar patency rates to standard polytetrafluoroethylene PTFE,

      Schild AF, Schuman ES, Noicely K, Kaufman J, Gillaspie E, Fuller J, et al. Early cannulation prosthetic graft (FlixeneTM) for arteriovenous access [published online ahead of print February 10, 2011]. J Vasc Access doi:10.5301/JVA.2011.6351.

      • Glickman M.H.
      • Stokes G.K.
      • Ross J.R.
      • Schuman E.D.
      • Sternbergh 3rd, W.C.
      • Lindberg J.S.
      • et al.
      Multicenter evaluation of a polytetrafluoroethylene vascular access graft as compared with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications.
      while decreasing the patient's exposure to a tunneled catheter. We have modified the insertion technique for the HeRO device to allow early access and avoid the infectious complications previously reported.

      Methods

      This study consisted of a concurrent cohort of patients in a vascular access practice. Patient data were obtained with each procedure, with follow-up data gathered during retrospective review. Patients were accrued into the study from January 2010 to August 2010.
      Standard HeRO devices were placed in a standard fashion up to the implantation of the graft component. Central access was obtained, and guidewires were manipulated to the atrium, usually with guiding catheter assistance (Figs 1 and 2). The HeRO outflow component was then placed after balloon angioplasty of central stenoses (Figs 3 and 4). The titanium connector portion of the graft component was attached to the outflow component in the upper chest near the deltopectoral groove (Fig 5). The graft was transected at the lateral end of the ringed segment of this connecting section (Fig 6). An early-access graft was then sutured to this part of the HeRO graft, tunneled to the selected artery, and anastomosed in a standard fashion. Removing the standard graft and suturing the early-use graft to this device adds <10 minutes to the procedure but does create a second anastomosis. This graft was then used for dialysis access in the patient's next session.
      Figure thumbnail gr1
      Fig 1Stenosis is shown in the innominate vein.
      Figure thumbnail gr2
      Fig 2A stiff guiding catheter wire has been inserted through the atrium to the inferior vena cava.
      Figure thumbnail gr3
      Fig 3A 10-mm balloon is used for angioplasty. An 8-mm vein is the minimum diameter for passage of the outflow component.
      Figure thumbnail gr4
      Fig 4The outflow component of the HeRO device is shown in the mid right atrium.
      Figure thumbnail gr5
      Fig 5The HeRO device is transected lateral to the titanium connector and the corrugated section of graft.
      Figure thumbnail gr6
      Fig 6The HeRO graft has been sutured to an early-use graft near the shoulder.

      Results

      Five patients underwent conversion of a HeRO device to an early-access graft. Flixene Grafts (Atrium Medical, Hudson, NH) were used for four of the five conversions. For the fifth patient, the HeRO graft was sutured to a previously placed PTFE graft that was promptly accessed. Three grafts were accessed ≤24 hours, one in 48 hours, and the last one in 72 hours. All were patent and used successfully. Four of the five grafts were used at flow rates >300 mL/min on their initial dialysis treatment. Occlusion developed in three grafts at 2 days, 3 days, and 2 months. All three patients were chronically hypotensive, with their blood pressure supported by the use of midodrine. In addition, one of the patients also had antiphospholipid syndrome. Patency was restored in two of these grafts and they continue to function at 3 and 6 months after thrombectomy. One young woman became agitated and demanded that her painful, occluded graft be completely removed. This was the only failure in this cohort.
      Four of the five early-access HeROs continue to function at an average of 5.5 months (range, 3-8 months). None have become infected. Warfarin therapy was started in one patient with multiple occlusions, with no further problems at 6 months of follow-up. All attempts to place this modification were successful.

      Discussion

      The HeRO device has been a useful addition to the vascular access surgeon's armamentarium. Many patients who were deemed “catheter-dependent” have an opportunity for graft access with its improved flow, more efficient dialysis, and a decreased chance of a morbid complication.
      Immediate-use grafts have been shown to be efficacious and safe, with a patency profile similar to PTFE. Combining these access materials gave us the ability to use the HeRO for the patient's next dialysis session without the need for a concomitant catheter. A similar approach was used by Vasquez et al
      • Vasquez J.C.
      • Delarosa J.
      • Rahim F.
      • Rahim N.
      Conversion of tunneled hemodialysis catheter into HeRO device can provide immediate access for hemodialysis.
      in their single case of converting an indwelling catheter to a HeRO while also attaching a Flixene graft for immediate use.
      As described in the Katzman series, the HeRO device carries a high infection burden when implanted while a tunneled dialysis catheter is simultaneously in use. They documented 24 overall infection events, and 7 bacteremias in 36 patients. The bridging catheters were in place an average of 38 days and were used in 88% of the patients. This is clearly a significant risk to the patient. They also describe a patient with an atrial clot and pulmonary embolism. It was not clear if that patient's bridging catheter was in the upper extremity or in a femoral site.
      We also experienced a catastrophic complication when a patient with an indwelling catheter underwent HeRO placement on the contralateral side, according to protocol. Chest discomfort developed in the first postoperative week, and she was brought to the emergency department. She quickly became dyspneic and died, despite full resuscitative efforts. Autopsy showed large thrombus in the superior vena cava around the HeRO outflow component and tunneled catheter with a massive pulmonary embolus. These two devices almost occluded her vena cava and led to the thrombus formation.
      No cost analysis was done, but the cost of the additional graft is more than the cost of a concomitant catheter. If the catheter were placed as a separate procedure, it would then be more costly than the graft alone. However, the cost of an infectious or thrombotic complication from the catheter, which is common, would be far greater than the cost of the additional graft.

      Conclusions

      The modification of the original insertion technique, as described in this article, will reduce infectious and clotting events by eliminating the simultaneous use of the HeRO and a dialysis catheter. The uniform success of immediate access was documented in these five patients. Their lack of infection events during 3 to 8 months of follow-up confirms the premise of Katzman et al that the cause of the bacteremias in their patients was the concomitant tunneled catheter. By increasing the safety profile of the HeRO, this technique can give the implanting surgeon and the patient decreased concerns about complications.

      References

        • Katzman H.E.
        • McLafferty R.B.
        • Ross J.R.
        • Glickman M.H.
        • Peden E.K.
        • Lawson J.H.
        Initial experience and outcome of a new hemodialysis access device for catheter-dependent patients.
        J Vasc Surg. 2009; 50 (607.e1): 600-607
        • Nassar G.M.
        Long-term performance of the hemodialysis reliable outflow (HeRO) device: the 56-month follow-up of the first clinical trial patient.
        Semin Dial. 2010; 23: 229-232
      1. Schild AF, Schuman ES, Noicely K, Kaufman J, Gillaspie E, Fuller J, et al. Early cannulation prosthetic graft (FlixeneTM) for arteriovenous access [published online ahead of print February 10, 2011]. J Vasc Access doi:10.5301/JVA.2011.6351.

        • Glickman M.H.
        • Stokes G.K.
        • Ross J.R.
        • Schuman E.D.
        • Sternbergh 3rd, W.C.
        • Lindberg J.S.
        • et al.
        Multicenter evaluation of a polytetrafluoroethylene vascular access graft as compared with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications.
        J Vasc Surg. 2001; 34: 465-472
        • Vasquez J.C.
        • Delarosa J.
        • Rahim F.
        • Rahim N.
        Conversion of tunneled hemodialysis catheter into HeRO device can provide immediate access for hemodialysis.
        Vasc Endovasc Surg. 2010; 44;: 687-690