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Use of Hemodialysis Reliable Outflow (HeRO) with Immediate Access Arteriovenous Grafts is Feasible
Uttara P. Nag, MD1, Megan C. Turner, MD1, Charles Fang, BS1, Jason K. Wagner, MD MS2, Mitchell W. Cox, MD1, Efthimios D. Avgerinos, MD2, Ellen D. Dillavou, MD1.
1Duke University, Durham, NC, USA, 2University of Pittsburgh, Pittsburgh, PA, USA.

Objective(s): In patients with central venous occlusive disease, combining immediate access arteriovenous grafts with the Hemodialysis Reliable Outflow (HeRO) graft presents a novel strategy to reduce or avoid catheter use. The Acuseal graft (W. L. Gore & Associates, Flagstaff, Ariz) has been approved for cannulation within 24 hours of placement, though its real-world performance has not been reported.Methods: All patients who underwent placement of Acuseal grafts from January 2014-April 2016 at two large tertiary referral centers were retrospectively identified in the electronic medical record. Patients who received this with a HeRO, or in anastomosis to an existing HeRO graft were included. When placed primarily, the Acuseal was anastomosed to the standard graft included in the HeRO kit approximately 3 cm from the connector to the silicone outflow. Demographic data, patency rates, time to cannulation, and infection were recorded. Patency was defined per Society for Vascular Surgery recommended reporting standards and determined from the time of index procedure. Outcomes were compared using Pearson χ2 tests for categorical variables and Wilcoxon rank-sum tests for continuous variables.
Results: Forty-four patients (mean age 58.414.6, 50% male) underwent placement of a combined Acuseal-HeRO graft. Mean follow up time was 7.68.6 months. Overall primary, primary assisted, and secondary patencies at 6 months were 35.9%, 43.6%, and 51.3% respectively. 95% of grafts were successfully cannulated, with mean time to cannulation of 13.051.6 days. One graft was excised prior to cannulation due to infection. 84% were cannulated within 14 days of placement with average first cannulation at 1.71.7 days. In the delayed cannulation group (>14 days), there was a significantly higher rate of graft infection compared to the early cannulation group (42.8 vs 8.1%, p=0.014). No access-related hematomas were observed. Patients were discharged on aspirin (13.6%), aspirin and clopidigrel (29.5%) or warfarin (20.5%), without patency differences. 7 patients underwent revision of an existing HeRO graft with Acuseal with mean follow up time of 9.711.9 months and with primary, primary assisted, and secondary patencies at 6 months of 40%, 40%, and 60%. One graft infection was observed in this group.
Conclusions: Acuseal-HeRO provides immediate access in patients with limited options, with reasonable patency and complication rates . Delayed graft cannulation is associated with higher rate of infection, likely related to prolonged catheter dwell time.


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