Two-stage Hemodialysis Reliable Outflow (HeRO) graft implantation technique that avoids the use of a femoral bridging dialysis catheter

Purpose: The purpose of this study is to report a novel two-stage Hemodialysis Reliable Outflow (HeRO) graft implantation technique that avoids the use of a femoral bridging hemodialysis catheter in internal jugular vein (IJV) catheter-dependent patients with contralateral central venous occlusion. Methods: The first stage is to implant the ePTFE component and consists of: 1) performing two to three incisions in the upper arm ipsilateral to the preexisting IJV catheter, 2) tunneling the expanded polytetrafluoroethylene (ePTFE) component through these incision sites, and 3) placing the ePTFE component in the subcutaneous tissue without anastomosing it to the target artery. The preexisting IJV catheter is maintained to provide continuous dialysis access. The second stage is initiated in 4 weeks and includes: 1) thrombectomy and anastomosing the ePTFE component arterial end to the target artery, 2) insertion of the venous outflow component using the preexisting IJV catheter access site, and 3) connecting the venous outflow component to the ePTFE component in the standard fashion. Results: The HeRO graft was successfully implanted in two stages without using a femoral bridging catheter. Immediate postimplant cannulatabilty was achieved upon completion of the second stage procedure. Conclusion: This novel two-stage HeRO implantation technique is simple, yet allows immediate cannulation upon completion of the second stage procedure while avoiding the need of a femoral bridging catheter in IJV catheter-dependent patients with contralateral central venous occlusion, and thus lowering the risk of infection related to a femoral bridging catheter.