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Alternative Access Technique for Percutaneous Thrombectomy in HeRO Graft
Derek Arrington, Sagar Gandhi, Christopher Carsten, III
Prisma Health, Greenville, SC
BACKGROUND: Maintaining access in end-stage renal disease (ESRD) can present unique challenges. Restoration of access patency in patients requiring the use of the Hemodialysis Reliable Outflow (HeRO) system is crucial as this group of patients has limited options for alternative access. Surgical history often limits sites available for use in either open or endovascular treatment. This case describes the first use of the transfemoral approach as a route for access for HeRO graft thrombectomy/intervention. METHODS: A 73-year-old male with longstanding ESRD and access via a right upper extremity HeRO graft presented with recurrent graft thrombosis. Access sites available for performing thrombectomy was complicated by significant scarring related to prior dialysis cannulations, numerous open/endovascular circuit interventions, previous grafts and fistula sites, and limited mobility from a previous fracture. This limited his sites for effective thrombectomy access and decision was made to approach the circuit retrograde via the right common femoral vein. The femoral vein was cannulated and an 8 French sheath was advanced into the right atrium. The HeRO graft was selected under fluoroscopic guidance and suction thrombectomy was performed. A high-grade stenosis was identified in the proximal brachial artery severely limiting inflow and treated with a covered stent. Additional intragraft stenosis was identified in the region of repeated cannulation requiring treatment with balloon angioplasty. Finally, a fibrin sheath was found at the level of the catheter outflow and treated with a 6 mm stent. With patency restored, hemostasis was obtained via manual pressure. RESULTS: Successful thrombectomy and percutaneous intervention of right upper extremity HeRO graft via right common femoral vein single access site. Graft was immediately available for dialysis. CONCLUSIONS: Long-term dialysis patients can be challenging in regard to providing effective continuous arteriovenous access. Patients requiring the use of HeRO grafts have limited options for alternative future access sites, therefore preserving the existing graft's patency becomes critical to the patient's survival. Percutaneous intervention for dialysis thrombectomy typically involves both antegrade and retrograde punctures away from cannulation sites. Open thrombectomy, likewise, requires an incision located in a region not being used for cannulation. In this case, numerous prior interventions limited his sites for open or endovascular access to his circuit. The femoral vein provided a single puncture site remote from the graft that could be used to successfully visualize and intervene on the entirety of the dialysis circuit. Although femoral access requires the use of longer devices, it provides a more ergonomic approach for the operator. It also offers decreased radiation exposure by increasing the distance from the radiation source and provides the opportunity for the use of enhanced shielding. Accessing the HeRO dialysis circuit via a single site femoral puncture allows for successful graft thrombectomy and complete dialysis circuit evaluation, while providing a safe and effective alternative to direct graft access. Single site access benefits both the patient and provider by improving ergonomics and minimizing the risk of further graft injury due to large bore direct graft access on patients with complex access anatomy.
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