C. Kensinger1, M. Nichols2, P. Bream2, D. Moore1 1Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Radiology And Radiological Sciences, Division Of Interventional And Vascular Radiology,Nashville, TN, USA
Introduction: The Hemodialysis Reliable Outflow (HeRO) dialysis access device is a permanent dialysis graft coupled to a central venous outflow component used in patients with end-stage dialysis access (ESDA) issues. Placement involves creation of an arterial anastomosis with the continuous venous outflow being delivered directly to the right atrium bypassing a stenosed or occluded central venous system. Compared to tunneled venous dialysis catheters, the HeRO graft has been shown to have superior patency rates, lower infection complications, lower associated costs, and superior dialysis flow rates. Given the potential for morbidity in ESDA patients secondary to medical comorbidities and multiple previous dialysis accesses, a multidisciplinary approach has been employed to maximize operative success in this complex patient population.
Methods: The multidisciplinary team consists of a nephrologist, an interventional radiologist, and a surgeon. Patients with suspected venous outflow stenosis or obstruction are referred to the ESDA clinic by the nephrologist. A computerized tomography angiogram/venogram is obtained and reviewed for anatomical consideration by the interventional radiologist. Based on the imaging and physical exam, laterality and a plan for access to the right atrium is jointly determined pre-operatively. In addition, an echocardiogram is obtained to ensure adequate right heart function given the increased venous return following HeRO placement. On the day of the procedure, access to the right atrium is first achieved in the interventional radiology (IR) suite. Using the resources available in the IR suite maximizes success for graft placement. In the OR, a 19F venous outflow component is exchanged for a placeholder catheter that was initially placed in the IR suite. Once the venous outflow component is successfully placed, the brachial arterial is exposed and the arterial inflow anastomosis to the HeRO graft is performed. The patient is discharged the day of surgery. The patient returns to clinic for evaluation prior to HeRO cannulation.
Results: Over the past 4 years, a multidisciplinary approach for HeRO placement has been used in 31 ESDA patients. 58% (18/31) of these patients have required advanced maneuvers in the IR suite in order to obtain central venous access. In these cases, angioplasty (5), recannulatization (5), or chest wall collateral access (8) was required to reach the right atrium. Access to the right atrium was achieved in 100% (31/31) cases. Two cases were aborted in the OR due to the inability to exchange the placeholder catheter for the 19F venous component. No intra-operative complications were encountered.
Conclusion: In this difficult patient population, a multi-disciplinary team can maximize operative placement of HeRO grafts in patients with complex central venous outflow obstruction. This in turn leads to higher success rates and decreased cost.