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HeRO, Gore Hybrid Graft and Other

Techniques for the No Option PatientStephen E. Hohmann, MD FACS

Vascular SurgeonBaylor University Medical Center

Dallas, Texas

DISCLOSURES• Speaker and consultant to Cryolife(products include the HeRO graft)

• Speaker for Gore (products include dialysis access grafts and stents)

Both of these will be discussed in this presentation

It’s Almost Always the Outflow If it were only this easy

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ACCESS REQUIREMENTS:1. Inflow (artery)2. Conduit (graft)3. Outflow (vein)

Main problem with dialysis access is the outflow ~ 90% failures

Intimal hyperplasia (scar tissue) tends to form atthe outflow leading to graft occlusion

Usually multiple repeated interventions are requiredto maintain patency

Access 101

Best Place for a Catheter!

Worst Place for a Catheter!

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Back to the Basics• History

– Number of catheters

– Last functioning access

–Which access functioned best?

– Anticoagulation?– Number of declots

Back to the Basics• Physical exam

– Look for scars– Chest wall– Pulses– Veins– Edema– Pacemaker/AICD

Must Look Venogram• A MUST FOR SUCCESS• Do before putting in access• Ultrasound guided access of brachial vein

• Micropuncture set• Look at both sides• Must see centrally

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Forgot to Look Stay away from AICD

All Too Familiar!! The HeRO Graft(Hemodialysis Reliable Outflow)

HeRO bypasses central venous stenosis

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Clinical OutcomesHeRO GraftGage, et al

EJVESHeRO GraftPatency

HeRO GraftKatzman,

JVSCatheter Literature

AVGLiterature

BacteremiaRates (infx/1,000days)

0.14 0.18 0.70 2.3 0.11

Adequacy of dialysis (mean Kt/V)

NA NA 1.7 1.29-1.46 1.37-1.62

Cumulative Patency

91% 88% 72% 37% 65%

Intervention Rate

1.5 1.7 2.5 5.8 1.6-2.4

Interest in HeRO Sparked by Central Venous Stenting

CC: Recurrent thrombosis of left arm av graftHPI: 50s year old hispanic male with left arm av graft. He notes his arm has been ballooned 15-20 times, cannot remember when stent was put in.

Same problem different side Anatomy Overview

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Success! Patient M.B.September 2014

• 74 year old female• ESRD, hypertension, urostomy, colostomy, infected left thigh graft with bleeding removed

• Right femoral permcath changed multiple time

• She was told no further accesses possible

Currently with Femoral Catheter

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HeRO outflow component in atrium

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Patient S.G.September 2014

• 40s• ESRD, CABG, HTN, DM II, left BKA, steal syndrome of right thigh av graft

• Left femoral permcath not functioning well

• Asked to evaluate for new permcath

Cath lab• Access brachial vein with micropuncture to determine central venous patency

• US guided access• Planning prior to going to the operating room

Clavicle

Subclavian Vein

Following Day in the OR

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Subclavian vein after angioplasty

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Completion angiogram

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Patient J.H.November 2014

• 31 year old male• ESRD, hypertension, multiple previous accesses

• Many permcaths• Left arm basilic vein transposition a number of years ago, now with arm and face swelling

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NOVEMBER 201470s year-old TDC dependent maleDiabetes II and HypertensionPE in office showed dilated chest wall veinsand multiple previous catheters

Monday 11/17/14 6PM Tuesday 11/18/14 9AM

Gore Hybrid Gore Hybrid

• Upside is creating access in upper arm without having to go onto chest

• Main issue is it is not early access graft

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SUMMARY • Always hit the reset button• Peritoneal dialysis may be an option• Avoid the pacemaker/AICD• Be sure to do venogram• Think hypercoagulable• Just because someone else said it could not be done – does not mean it is true

The MOST DISRUPTIVE TECHNOLOGY IN DIALYSIS ACCESS

RECENTLY HAS BEEN: A. Central Venous SteningB. HeRO graft developmentC. Early Access GraftsD. BiologicsE. GORE Hybrid

C e nt r a l

V en o u

s S te n i

n g

H e RO g

r a f t d e

v e l op m

e n tE a r

l y Ac c e

s s Gr a f t

sB i o

l o gi c s

G OR E

H y br i d

56%

15% 15%

4%11%

How Old Am I?

A.88B.98C.105D.111

Happiness

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Questions?