Modified Proximalization Of Arterial Inflow Using A Hero Graft
Sebastian Cifuentes, MD, Armin Tabiei, Medical Student, Manju Kalra, M.B.S.S, Bernardo Mendes, M.D, Randall DeMartino, M.D.
Mayo Clinic, Rochester, MN, USA.
Demographics: We present a 63-year-old male with end-stage renal disease with multiple failed vascular accesses, referred for creation of permanent dialysis access. At first encounter, the patient was on chronic anticoagulation and hemodialysis via a translumbar catheter. History: The patient had a failed kidney transplant, aortic valve replacement, severe coronary artery disease, two coronary artery bypass grafts, and hypertension. Previous vascular access included right groin and upper extremity, complicated by chronic deep and central vein thrombosis. Additionally, he underwent stenting of the right innominate and superior vena cava (SVC) due to SVC syndrome. Plan: The patient was initially offered placement of a Hemodialysis Reliable Outflow (HeRO) graft as the best permanent option for vascular access. Ultrasound-guided access to the right internal jugular vein (IJV) was obtained, and balloon dilation of the previous IVC stent was done to maximize the lumen. The venous outflow component of the HeRO graft was placed at the right atrial junction. After tunnelization, the proximal 6mm PTFE component was sewn end-to-side to the brachial artery above the antecubital crease. After one month, the patient developed severe right-hand pain during dialysis and ulceration of the third finger, findings consistent with arteriovenous (AV) steal. Distal revascularization with interval ligation (DRIL) was planned, but saphenous vein was not adequate. Thus, proximalization of arterial inflow (PAI) was considered the best surgical option to preserve the HeRO graft access. A 6mm PTFE graftwas anastomosed end-to-side to the axillary artery and tunneled down to the brachial artery. The previous PTFE graft was disconnected from the brachial artery and sewn end-to-end to the new PTFE graft creating a loop (Figure). After one month, the pain and finger wound resolved, and dialysis could be started through the HeRO graft. Ultrasound showed normal flow and patency after three months. Discussion: Ensuring permanent vascular access for patients with end-stage kidney disease is challenging. HeRO graft is an acceptable option for patients with failed AV fistulas; however, dialysis access-induced ischemia due to AV steal prevented the patient from utilizing the graft. PAI was an appropriate alternative, achieving preservation of the HeRO graft and symptoms resolution.
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