Arteriovenous grafts (AVGs) provide vascular access for hemodialysis in patients with end-stage renal disease (ESRD). However, vascular access thrombosis often occurs, requiring frequent reinterventions to maintain access patency. This report describes the successful use of the InThrill Thrombectomy System (Irvine, CA: Inari Medical) for macerating and removing thrombus from an occluded and heavily thrombosed AVG. A 47-year-old male was sent to our institute for a thrombosed right upper extremity arteriovenous access with a HeRO graft (South Jordan, UT: Merit Medical). The patient underwent interventions for the thrombosis of the same AVG two weeks prior using an Aspirex catheter (Franklin Lakes, NJ: BD Medical), and again two days prior with a Fogarty balloon catheter (Irvine, CA: Edwards Lifesciences). The patient presented with a recurrent completely occluded AVG. Using the InThrill Thrombectomy System and balloon angioplasty, the stenosis was reduced to less than 20%, resulting in brisk flow. The patient tolerated the procedure well without complication and recovered in the holding area with no acute distress. He was discharged the same day on anticoagulation therapy. This study highlights the successful use of the InThrill Thrombectomy System for the treatment of thrombosed AVG in a hemodialysis-dependent ESRD patient. The device was easy to use and efficient. Device and procedure times are unparalleled when compared with thrombolytic-based procedures. The patient\'s AVG remained patent at a 14-day follow-up.

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.

UNASSIGNED: Hemodialysis Reliable Outflow (HeRO) grafts are used when venous outflow is inadequate to support conventional access. These have been perceived as complex to implant and being associated with high risk. We have evolved a defined protocol for insertion that minimizes morbidity and maximizes efficiency.
UNASSIGNED: Our protocol includes staged intravenous access versus HeRO graft placement, reverse Trendelenburg positioning, subcutaneous access of the deep portion of the existing catheter, use of a stiff wire placed within the inferior vena cava, dilation of the tract to 8 mm, device lubrication, all insertion procedures directly visualized, and use of immediate access conduits with SuperHeRO connector.
UNASSIGNED: From 7/1/18 to 8/13/19, 55 HeRO grafts were placed at our institution following this protocol, average age 58 ± 15 (26-86) years (mean ± SD, range). 53 (96%) had had prior ipsilateral central access (13 by means of \"inside out\" 2 weeks prior) the other two had on-table access. Mean procedure time was 70 ± 26 (38-148) min. Excluding seven \"complex\" cases, procedure time for our first 20 cases using this protocol was 72 ± 29 min, while that of the last 28 was 62 ± 18 min (p < 0.05). One patient suffered acute CHF after unclamping; despite reclamping and ligation he died on POD 3 (mortality rate 2%). 71% were done as outpatients, and 47 of 53 evaluable patients (89%) had their grafts used within 36 h for dialysis. Only one patient (2%) has had an infection within 30 days (cellulitis). At a mean followup of 95 ± 105 (maximum 383) days, three additional patients have had graft infections requiring excision, for a total infection rate of 5/53 (9%).
UNASSIGNED: Our results suggest that HeRO graft placement can be performed with minimal morbidity and mortality on an outpatient basis. Short-term infection rates are low and 89% of patients have their grafts immediately accessed and are discharged without a catheter.

UNASSIGNED: The use of the HeRO system with the early-access ACUSEAL graft avoids the need for a tunnelled dialysis catheter as a bridge for vascular access. Established complications of this system include thrombosis, graft infection, haematoma, and pseudoaneurysm formation.
UNASSIGNED: A 72-year-old patient found to have a dissection flap at the venous cannulation point (ACUSEAL component) of a right arm HeRO graft. The ACUSEAL was replaced in theatre and subsequent duplex imaging confirmed satisfactory graft function.
UNASSIGNED: This case demonstrates a serious yet previously undescribed complication of cannulation of an ACUSEAL graft. The trilaminar construction of the graft may increase the likelihood of disruption of the luminal layer during repeated needling and predispose it to dissection. Given the consequences of graft failure in such patients, urgent intervention is warranted when graft dissection is suspected.

Creating durable vascular access has become more complicated with the improvement of the management and with the increasing survival of patients with end-stage renal disease. HeRO (Hemodialysis Reliable Outflow) graft allows to maintain vascular access on the upper limb in patients with the presence of bilateral central venous occlusion. Our institute was the first in Hungary to perform a HeRO graft implantation in a patient receiving regular hemodialysis. Our objective was to present our findings with this recent innovation. Case report, medical documentation and imaging studies were reviewed. The patient (73-year-old, female) has been receiving hemodialysis since 12 years with the history of several arteriovenous fistula (AVF) creations, thrombectomies, use of central venous catheter in both sides. Following the occlusion of a left cubital arterio-venous fistula, none of the conventional vascular access types could have been performed due to bilateral subclavian vein occlusion. Successful HeRO graft implantation was performed. The patient underwent graft thrombectomy and endovascular intervention 7 and 12 months after the original procedure. After both reoperations, the graft functioned well for hemodialysis. HeRO graft can be a good alternative to central venous catheters and lower limb arterio-venous grafts in cases of bilateral central venous occlusion. Orv Hetil. 2019; 160(31): 1231-1234.
Absztrakt: A végstádiumú veseelégtelen betegek kezelésének folyamatos fejlődése és túlélési eredményeinek javulása következtében egyre nagyobb kihívást jelent tartós, jól működő arteriovenosus összeköttetés létrehozása. A HeRO (Hemodialysis Reliable Outflow) rendszer lehetővé teszi megfelelően funkcionáló arteriovenosus sönt képzését olyan betegekben, akiknél mindkét oldali centrális vénás elzáródás miatt felső végtagi sönt készítése már nem jönne szóba. Hazánkban először ültettünk be eredményesen HeRO graftot egy tartós hemodialízisben részesülő betegnél. Célunk az ezzel kapcsolatos tapasztalataink bemutatása. Esetismertetésünkben a betegdokumentációt, a pre- és posztoperatív képalkotó vizsgálatokat tekintettük át. Betegünk (73 éves nő) 12 éve részesül rendszeres hemodialíziskezelésben. Mindkét felső végtagon számos alkalommal történt arteriovenosus fistula létrehozása, fistulathrombectomia, valamint mindkét oldalon sor került tartós tunelizált dialíziskanül használatára. Bal oldali könyöktáji fistulájának elzáródását követően konvencionális sönt képzése nem jött szóba a mindkét oldalon kialakult vena subclavia occlusióra tekintettel, ezért HeRO graft implantációja mellett döntöttünk. A sikeres graftimplantációt követően 7, majd 12 hónappal történt graftthrombectomia és endovascularis intervenció, melyet követően ismét jó hatásfokú hemodialízis végezhető a grafton keresztül. A mindkét oldali felső testfél centrálisvéna-occlusiója esetén a HeRO graftrendszer megfelelő alternatívája lehet a tunelizált dialíziskanülöknek és alsó végtagi arteriovenosus összeköttetéseknek. Orv Hetil. 2019; 160(31). 1231–1234.

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.

暂无摘要。

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.