Advertisement

Modified use of the Hemodialysis Reliable Outflow (HeRO) graft for salvage of threatened dialysis access

Open ArchivePublished:May 28, 2012DOI:https://doi.org/10.1016/j.jvs.2012.04.013
      The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere Inc, Eden Prairie, Minn) offers a new option to provide upper extremity arteriovenous (AV) dialysis access in patients with central venous occlusive disease. Creative use of this device can allow for salvage of failing or threatened AV fistulas and grafts. We present two patients who underwent a modified implantation of the HeRO device for immediate salvage of a malfunctioning AV access. Ipsilateral central venous occlusions were successfully overcome by anastomosing a HeRO device to the existing AV access and tunneled across the chest to the contralateral internal jugular vein.
      Long-term hemodialysis access is an increasing problem, with a growing number of patients becoming hemodialysis-dependent and spending longer lengths of time on hemodialysis. Despite its relatively new use, recent data suggest similar function and patency rates of Hemodialysis Reliable Outflow (HeRO) grafts (Hemosphere Inc, Eden Prairie, Minn) compared with arteriovenous (AV) grafts,
      • 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.
      • Nassar G.M.
      Long-term performance of the hemodialysis reliable outflow (HeRO) device: the 56-month follow-up of the first clinical trial patient.
      along with decreased bacteremia, improved patency rates, and improved adequacy of dialysis compared with tunneled dialysis catheters in patients with difficult access.
      • 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.
      Failed AV fistulas or grafts are often the result of access-related thromboses, infections, and multiple central venous occlusions. In many instances, such patients will be faced with a malfunctioning upper extremity AV access due to worsening central venous outflow stenosis. We present a modified technique in which the HeRO device was used for the salvage of a functioning, yet threatened, upper extremity AV access in the setting of extremely limited central venous outflow options.

      Case reports

       Patient 1

      A 69-year-old diabetic African American man, with end-stage renal disease and who had received hemodialysis for 5 years, presented complaining of right arm swelling and pain, worsened by hemodialysis. His dialysis access consisted of a right 4- to 7-mm tapered brachioaxillary AV graft (AVG) of expanded polytetrafluoroethylene. He had previously undergone a left basilic vein transposition and a left brachioaxillary graft placement, which subsequently became infected and was excised.
      In a dedicated special-procedures hybrid operating room, a fistulogram demonstrated an occlusion of the right subclavian vein without clear reconstitution of the right internal jugular vein (IJV) or subclavian confluence, along with extensive collateralization. Endovascular attempts at recanalization of the right subclavian vein were unsuccessful. Central venography from a femoral vein approach demonstrated an occluded right IJV, but a patent superior vena cava, left innominate vein, left subclavian, and IJV.
      Ultrasound guidance was used to access the left IJV, and a wire was passed into the right atrium under fluoroscopic guidance. After central venous access to the superior vena cava was established, the venous outflow component of the HeRO device was introduced after serial dilation of the tract. The device was tunneled subcutaneously across the anterior chest wall to a counter incision at the right (contralateral) deltopectoral groove, where the 6-mm HeRO graft was coupled to the venous outflow component (Fig, arrow). Care was taken to maintain the tunnel of the HeRO device under the sternal notch, and due to the rigidity of the device, no kinking was appreciated on fluoroscopy.
      Figure thumbnail gr1
      FigCompletion fistulogram demonstrates flow into the right atrium through the graft and the Hemodialysis Reliable Outflow (HeRO) device. The arrow depicts the HeRO-expanded polytetrafluoroethylene graft to the venous outflow component-coupling site. AVG, Arteriovenous graft; AX V, axillary vein.
      A 2.5-cm incision was made at the distal (venous) end of the AVG, and the HeRO graft was further tunneled from the coupler incision site to the AVG incision site in the upper arm. After obtaining proximal and distal control and infusing intravenous heparin (3000 units), the new polytetrafluoroethylene-HeRO system was anastomosed in an end-to-side fashion to the existing graft. A completion fistulogram performed through a micropuncture of the graft revealed brisk flow through the HeRO into the right atrium (Fig). The operative time was approximately 4 hours. The patient had an estimated blood loss of 200 mL and no intraoperative complications.
      Dialysis was reinstituted the next day using the pre-existing graft, with dialysis flow rates of 420 mL/min compared with preoperative dialysis flow rates of 400 mL/min. The patient has successfully continued hemodialysis through the HeRO device for 14 months, without complications and with relief of his preoperative symptoms.

       Patient 2

      A 64-year-old man with a history of end-stage renal disease and multiple failed bilateral upper extremity fistulas had been receiving chronic hemodialysis for 10 years. He was evaluated after the dialysis unit noted clots in the equipment tubing and loss of a palpable thrill over his right brachiocephalic AV fistula, which had been created 2 years prior. After an initial evaluation, the interventional radiology service successfully thrombectomized the fistula and performed a fistulogram that revealed occlusion of the right subclavian/innominate veins, with unsuccessful attempts at recanalization. A left IJV tunneled catheter was placed to provide a viable dialysis access.
      Given this patient's ipsilateral central occlusions and no usable arm veins, we opted to place a HeRO device as described in patient 1. The left tunneled dialysis catheter was exchanged for the venous outflow component of the HeRO device, as previously described,
      • Vasquez J.C.
      • DeLaRosa J.
      • Rahim F.
      • Rahim N.
      Conversion of tunneled hemodialysis catheter into HeRO device can provide immediate access for hemodialysis.
      positioned under fluoroscopic guidance, and anastomosed, as described in patient 1, with the exception that no systemic anticoagulation was given. A completion fistulogram revealed good flow through the fistula, into the HeRO device, and into the right atrium. The case was performed in a dedicated special-procedures hybrid operating room suite and lasted 3 hours, with an estimated blood loss of 100 mL.
      Postoperatively, the patient had minor erythema around the right chest incision, which was treated with a 10-day course of Augmentin (GlaxoSmithKline, London, UK). He has continued receiving dialysis through his native fistula with the modified HeRO device outflow for 5 months, with no other complications. The postoperative flow rate of dialysis was 450 mL/min compared with a preoperative flow rate of 400 mL/min.

      Discussion

      The rising number of chronic hemodialysis patients has resulted in an increased incidence of failed AV accesses, upper extremity venous hypertension, and limited central venous outflow options.
      • El-Sabrout R.A.
      • Duncan J.M.
      Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option.
      • Anaya-Ayala J.E.
      • Bellows P.H.
      • Ismail N.
      • Cheema Z.F.
      • Naoum J.J.
      • Bismuth J.
      • et al.
      Surgical management of hemodialysis-related central venous occlusive disease: a treatment algorithm.
      Surgical creativity in the setting of salvaging threatened but functioning accesses with few alternate placement sites becomes paramount. Previous publications have documented successful implantation of the HeRO as well as endovascular techniques to manage occlusive episodes.
      • Vasquez J.C.
      • DeLaRosa J.
      • Rahim F.
      • Rahim N.
      Conversion of tunneled hemodialysis catheter into HeRO device can provide immediate access for hemodialysis.
      • Vasquez J.C.
      • DeLaRosa J.
      • Leon J.J.
      • Rahim N.
      • Rahim F.
      Percutaneous endovascular management of occluded HeRO dialysis access device.
      • Fusselman M.
      Results of a customer-based, post-market surveillance survey of the HeRO access device.
      • Schuman E.
      • Ronfeld A.
      Early use conversion of the HeRO dialysis graft.
      We have presented another option for immediate salvage when the only central venous outflow may be the contralateral IJV, allowing for continued use of the functioning access and preservation of the graft or fistula.
      Endovascular therapy has become the standard of care for ipsilateral central venous stenoses or occlusions that can be traversed. National Kidney Foundation Disease Outcomes Quality Initiative guidelines recommend angioplasty combined with stenting for elastic central vein stenoses or recurrent stenoses within a 3-month period.
      National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NFK KDOQI)
      Clinical practice guidelines for vascular access: 2006 updates Guideline 6. Treatment of arteriovenous graft complications.
      Primary patency rates for these interventions are 12% to 29% at 12 months, with cumulative patency rates of 69% to 100%.
      • Farber A.
      • Barbey M.M.
      • Grunert J.H.
      • Gmelin E.
      Access-related venous stenoses and occlusions: treatment with percutaneous transluminal angioplasty and Dacron-covered stents.
      • Quinn S.F.
      • Schuman E.S.
      • Demlow T.A.
      • Standage B.A.
      • Ragsdale J.W.
      • Green G.S.
      • et al.
      Percutaneous transluminal angioplasty versus endovascular stent placement in the treatment of venous stenoses in patients undergoing hemodialysis: intermediate results.
      Unfortunately, these procedures have limited patency and high recurrence rates requiring multiple interventions and potential complications. Furthermore, a subset of patients has occlusions that cannot successfully be treated endovascularly and previous failed fistulas/grafts have exhausted all potentially usable access sites. Throughout the past decade, numerous complex surgical techniques have been offered to approach chronic total occlusions of the central veins. These have included bypasses performed via sternotomy, claviculectomy, and long bypasses from the upper extremity to the femoral venous system. These approaches are highly invasive and carry significant morbidity and mortality.
      • Anaya-Ayala J.E.
      • Bellows P.H.
      • Ismail N.
      • Cheema Z.F.
      • Naoum J.J.
      • Bismuth J.
      • et al.
      Surgical management of hemodialysis-related central venous occlusive disease: a treatment algorithm.

      Conclusions

      The patients described present a hybrid endovascular and minimally invasive open surgical approach whereby a threatened AV access with an ipsilateral central vein occlusion was bypassed to the right atrium through the contralateral jugular vein. Advantages of this approach include salvage of the failing access, immediate use of access after the procedure, and decreased need for temporary indwelling catheters. This modified HeRO technique can serve as an option for properly selected chronic hemodialysis patients with complex central venous stenoses.

      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 (7e1): 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
        • 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
        • El-Sabrout R.A.
        • Duncan J.M.
        Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option.
        J Vasc Surg. 1999; 29: 472-478
        • Anaya-Ayala J.E.
        • Bellows P.H.
        • Ismail N.
        • Cheema Z.F.
        • Naoum J.J.
        • Bismuth J.
        • et al.
        Surgical management of hemodialysis-related central venous occlusive disease: a treatment algorithm.
        Ann Vasc Surg. 2011; 25: 108-119
        • Vasquez J.C.
        • DeLaRosa J.
        • Leon J.J.
        • Rahim N.
        • Rahim F.
        Percutaneous endovascular management of occluded HeRO dialysis access device.
        Vasc Endovasc Surg. 2010; 44: 44-47
        • Fusselman M.
        Results of a customer-based, post-market surveillance survey of the HeRO access device.
        Nephrol News Issues. 2010; 24: 30-33
        • Schuman E.
        • Ronfeld A.
        Early use conversion of the HeRO dialysis graft.
        J Vasc Surg. 2011; 53: 1742-1744
        • National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NFK KDOQI)
        Clinical practice guidelines for vascular access: 2006 updates.
        (New York: National Kidney Foundation) (Accessed February 12, 2012)
        • Farber A.
        • Barbey M.M.
        • Grunert J.H.
        • Gmelin E.
        Access-related venous stenoses and occlusions: treatment with percutaneous transluminal angioplasty and Dacron-covered stents.
        Cardiovasc Interv Radiol. 1999; 22: 214-218
        • Quinn S.F.
        • Schuman E.S.
        • Demlow T.A.
        • Standage B.A.
        • Ragsdale J.W.
        • Green G.S.
        • et al.
        Percutaneous transluminal angioplasty versus endovascular stent placement in the treatment of venous stenoses in patients undergoing hemodialysis: intermediate results.
        J Vasc Interv Radiol. 1995; 6: 851-855