OBJECTIVE: The HeRO graft is a technique for vascular access in patients with limited treatment options; however, the published results with the HeRO graft are diverging. We therefore conducted a single-center study.
METHODS: Patient records between July 2014 and February 2020 from Vascular Access Unit of the Department of Vascular and Endovascular Surgery of University Clinic of Cologne (Germany) were reviewed. Retrospective data was analysed from patients with a HeRo graft (n = 18).
RESULTS: Eighteen patients were enrolled in the study. The mean age of the patients was 62.8 ± 17.24 years. During the follow-up period, no patients died from complications related to the HeRO graft. Each patient had a mean of 1.94 concomitant diseases. The primary patency rates of the HeRO graft at 3, 6, 12, 18, and 24 months were 61.1%, 50%, 16.7%, 11.1%, and 5.6%, respectively. The secondary patency rates at the same time intervals were 77.8%, 72.8%, 55.6% 55.6%, and 55.6%, respectively. There were 44 re-operations per year, or 2.4 operations per patient. The main cause of acute complications was acute graft occlusions after HERO graft implantation. An infection after the graft implantation occurred in five (27.7%) patients, leading to graft explanation in 2 cases.
CONCLUSIONS: The use of the HERO graft is a valuable alternative method for providing a durable dialysis access in patients with limited access options. The secondary patency and survival are good with a low infection rate.

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.

Population aging and prolonged time on dialysis pose challenges to vascular access for nephrologists and vascular surgeons. HeRO grafts are an option used for patients with central venous obstruction and without the possibility of other vascular access on upper limbs. Some long-term complications, namely access thrombosis, infection, and limb ischemia, have already been reported. There are few data on thromboembolic complications associated with this device. We report the first case in the literature of Budd-Chiari Syndrome associated with the HeRO graft.

Current vascular access (VA) practice adopts arteriovenous fistulas (AVF) as first option for haemodialysis, relegating arteriovenous grafts (AVG) for patients with exhausted upper limb venous patrimony. The Hemodialysis Reliable Outflow graft (HeRO®) is a device assuring direct venous outflow to the right atrium, thus avoiding central venous obstructive disease. Its use together with early access grafts avoids the need for central venous catheters (CVC) bridging periods. We report the deployment of the HeRO device using a previous stentgraft as pathway for the placement of the outflow component, in a patient with no-option for further autogenous upper limb access. This technique spared the usual central vein\'s exit point for the HeRO graft and, using an early-access dialysis graft, allowed for next-day successful haemodialysis.

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: Stenting of central venous stenosis to preserve upper extremity hemodialysis access is well-described, though upper extremity complications secondary to these stents are less frequently discussed.
UNASSIGNED: We present the case of a 43-year-old male with a right brachiocephalic fistula who developed symptoms of venous hypertension following placement of a Wallstent for central venous stenosis. Workup demonstrated venous outflow obstruction secondary to stent foreshortening into the right subclavian vein.
UNASSIGNED: The Wallstent was removed in a piecemeal fashion using an open surgical technique and a HeRO graft was placed for dedicated fistula outflow with complete relief of the patient\'s symptoms.
UNASSIGNED: In situations where a stent has migrated and endovascular removal is not possible, individual Wallstent fibers can be removed through a limited venotomy.

BACKGROUND: The purpose of this study was to assess the feasibility and outcomes of recanalization and subsequent HeRO graft outflow component insertion across stent interstices in patients with an otherwise abandoned upper extremity.
METHODS: Over a 10-year period, 15 patients underwent central venous recanalization by interventional radiology across the interstices of one or more occluded stents for the purpose of subsequent HeRO graft creation. A tunneled central venous catheter was left across the stent and occlusions with tip in right atrium. On a later date, the catheter was used for rapid guidewire access for HeRO graft implantation in the OR by vascular surgery. Procedural and clinical outcomes were determined by retrospective review. Primary and secondary HeRO graft patency rates were estimated with the Kaplan-Meier technique.
RESULTS: The technical success rates of recanalization across stent interstices was 100% (15/15). Between one and four overlapping stent walls were traversed. The technical success of the patients who underwent attempted HeRO graft implantation with outflow component traversing across stent interstices was 91% (11/12). No major complications were encountered with either recanalization or HeRO graft implantation. The primary and secondary HeRO patency rates at 12 months were 64% and 80%, respectively.
CONCLUSIONS: HeRO graft insertion across stent interstices is feasible and can provide effective permanent AV access; thus, the presence of stents across the subclavian and brachiocephalic veins should not be considered a contraindication.

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.