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Perioperative and Long-Term Outcomes after Hemodialysis Reliable Outflow (HeRO) Graft Surgery: Results of a Ten-Year Experience
Christina L Cui
1, Tristen T Chun
1, Charles Y Kim
1, Ellen D Dillavou
2, Mitchell W Cox
3, Kevin W Southerland
1, Young Kim
1 1Duke University Medical Center, Durham, NC;
2WakeMed Health, Raleigh, NC;
3University of Texas Medical Branch, Galveston, TX
BACKGROUND:The Hemodialysis Reliable Outflow (HeRO) graft offers hemodialysis access options for patients who have developed central venous stenosis or occlusion. In this single-center study, we report our perioperative and long-term outcomes after HeRO graft placement, and investigate the impact of conduit type and configuration on patency rates.
METHODS:We retrospectively reviewed all HeRO graft procedures performed from January 2014 to December 2023 across three hospitals. Data were collected on patient demographics, operative details, postoperative outcomes, and patency. Only index HeRO graft procedures were included, and any subsequent or reoperative HeRO operations were excluded from analysis. Cox proportional hazards model was used to derive risk factors for loss of graft patency.
RESULTS:A total of 232 index HeRO implantations were performed over the ten-year study period. These included 49 (23.1%) primary procedures and 183 (78.9%) staged procedures. Postoperative complications included wound infection (n=18, 7.8%), symptomatic hematoma (n=23, 9.9%), steal syndrome (n=23, 9.9%), myocardial infarction (n=3, 1.3%), and pulmonary embolism (n=7, 3.0%). Overall primary patency was 33.0±3.4% at one year, 6.4±2.1% at three years, and 4.3±1.9% at five years post-implantation. (Figure 1) Secondary patency was 69.4±3.4% at one year, 41.9±4.4% at three years, and 28.0±4.9% at five years post-implantation. Primary and secondary patency rates did not differ between primary and staged procedures (log-rank p=0.46 and 0.73, respectively). On multivariate analysis, the use of a tapered 4-6 mm (hazard ratio [HR] 2.89, 95% confidence interval [CI], 1.11-7.49, p=0.029) or tapered 4-7 mm conduit (HR 1.82, 95% CI, 1.15-2.87, p=0.011) was independently associated with loss of primary patency, compared with a non-tapered 6 mm graft. Tapered conduits were also associated with loss of secondary patency (4-6 mm tapered; HR 3.68, 95% CI, 1.07-12.63, p=0.039; 4-7 mm tapered; HR 1.85, 95% CI, 1.01-3.37, p=0.044). Neither graft type (standard vs early cannulation) nor procedure (primary vs staged) were associated with loss of primary or secondary patency. (Table 1)
CONCLUSIONS:Among patients with limited hemodialysis access options, HeRO graft implantation is associated with limited primary patency but acceptable secondary graft patency rates. In our experience, staged procedures and early-cannulation grafts did not impact patency rates, however, the use of a tapered conduit was associated with loss of patency and should be considered with caution in this patient population.
Table 1: Graft and procedure factors associated with loss of HeRO graft primary patency | | Hazard Ratio | 95% Confidence Interval | P-value |
| Graft Type | Standard PTFE | Reference | | |
| Early Cannulation PTFE | 1.18 | (0.80-1.75) | 0.410 |
| Graft Size | 6mm Non-tapered | Reference | | |
| 4-6mm Tapered | 2.89 | (1.11-7.49) | 0.029 |
| 4-7mm Tapered | 1.82 | (1.15-2.87) | 0.011 |
| Procedure Type | Primary HeRO | Reference | | |
| Staged HeRO | 0.97 | (0.65-1.45) | 0.890 |
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