A.N. Eze1, C.L. Cui1, K.W. Southerland1, Y. Kim1 1Duke University Medical Center, 1. Division Of Vascular And Endovascular Surgery, Department Of Surgery, Durham, NC, USA
Introduction: When all upper extremity access options have been exhausted and patients are dependent on less optimal options like tunneled dialysis catheters and femoral grafts, the Hemodialysis Reliable Outflow (HeRO) graft is the last option available to re-establish upper extremity access in complex end-stage renal disease patients. Access-related hand ischemia (ARHI) is a serious complication following creation of hemodialysis access, however, the incidence and risk factors for ARHI after HeRO graft implantation have not been previously reported.
Methods: Institutional medical records were retrospectively reviewed for all index HeRO graft implantation procedures performed between 2014 to 2023. Re-do HeRO grafts were excluded from analysis. Data were collected on patient demographics, comorbidities, operative details, and postoperative outcomes. The primary outcome of interest was symptomatic ARHI following HeRO surgery. Statistical analysis was performed using univariate tests, logistic regression analysis, and Kaplan-Meier estimates for patency.
Results: A total of 232 index HeRO surgeries were performed over the ten-year study period, of which 23 (9.9%) developed symptomatic ARHI. Patients with ARHI were older than their counterparts (64.0±13.7 vs 57.0±13.3 y, p=0.008). All other demographic factors and medical comorbidities were similar between groups. In terms of inflow vessel, patients with ARHI more frequently underwent brachial artery anastomosis (78.3% vs 65.1%), and were less frequently anastomosed to a previously placed arteriovenous graft or fistula (8.7% vs 25.8%, p=0.04). The use of a tapered graft was similar between ARHI and non-ARHI groups (47.8% vs 31.1%, p=0.10). There were no differences in anticoagulant or antiplatelet medication use (p=0.96). On multivariable analysis, only patient age (hazard ratio [HR] 1.06 per year, 95% CI 1.02-1.10, p=0.003) was independently associated with symptomatic ARHI after HeRO procedure. Tapered graft utilization was not associated with reduced risk of ARHI (HR 0.75, 95% CI 0.23-2.38, p=0.61). Patients with ARHI had significantly higher 30-day hospital readmission rates (34.8% vs 17.7%, p=0.0049) and significantly reduced secondary graft patency rates (one-year: 46.0±11.4% vs 71.3±3.6%; three-year: 23.7±11.1% vs 44.0±4.8%, p=0.01).
Conclusion: Symptomatic ARHI can occur in at least 9.9% of patients after HeRO graft implantation and portends inferior long-term outcomes. Tapered conduits were not associated with reduced risk of ARHI, and based on our previous work, may result in reduced primary and secondary patency rates. These data are valuable for informed consent and shared decision-making among patients undergoing HeRO graft surgery.