Abstract from the 2013 Midwestern Vascular Surgical Society Annual Meeting| Volume 58, ISSUE 5, P1437, November 01, 2013

A Novel Two-Stage HeRO Graft Implantation Technique that Avoids the Use of a Femoral Bridging Hemodialysis Catheter in Selected Patients

      For patients with no adequate upper extremity peripheral venous outflow, the Hemodialysis Reliable Outflow (HeRO) graft can provide an opportunity for an upper extremity subcutaneous arteriovenous (AV) dialysis graft. However, in the subset of patients who have an internal jugular vein (IJV) catheter and contralateral central venous occlusion, a femoral bridging catheter, which carries a high infection burden, is required during the graft incorporation. Short of using an immediately cannulatable AV graft sewn to a HeRO coupling device, we present here a novel two-stage HeRO graft implantation technique that avoids the use of a femoral bridging catheter in this subset of patients. The first stage of this technique is to implant the ePTFE component (EC). The EC is tunneled subcutaneously in the upper arm ipsilateral to a concurrent IJV catheter in a gentle curve or loop, from the arterial anastomosis incision site to the connector incision site in the deltoid area. Then, instead of anastomosing to the target artery, the proximal arterial end of the EC is folded over and placed in the subcutaneous tissue. The preexisting IJV catheter is maintained to provide continuous dialysis access. The second stage of the operation is initiated in 3 to 4 weeks by reopening the arterial incision site with dissection to free the target artery. The connector incision site is also reopened to dissect this end free. Next, the EC arterial end within the subcutaneous tissue is unfolded, thrombectomized, irrigated, and anastomosed to the freed target artery. The chest wall catheter is then freed up from its exit site, and the jugular entrance site is opened. After clamping the catheter at the entrance site, it is transected, and the external part is cleared from the field. A stiff wire is then placed through the remaining part of the catheter and the residual catheter is removed. In the following step, the venous outflow component, which is tunneled from the IJV site to the EC connector site, is placed through the peel-away sheath until its tip is located at the cavo-atrial junction. Finally, the distal portion of the venous outflow component is attached to the ePTFE graft in the standard fashion, completing the HeRO graft implantation in two stages without using a femoral bridging catheter.