4/17/2015 HeRO, Gore Hybrid DISCLOSURES Graft and Other • Speaker and consultant to Cryolife (products include the HeRO graft) Techniques for the No • Speaker for Gore (products include Option Patient dialysis access grafts and stents) Stephen E. Hohmann, MD FACS Both of these will be discussed in this presentation Vascular Surgeon Baylor University Medical Center Dallas, Texas It’s Almost Always the Outflow If it were only this easy 1
4/17/2015 Access 101 ACCESS REQUIREMENTS: 1. Inflow (artery) 2. Conduit (graft) 3. Outflow (vein) Main problem with dialysis access is the outflow ~ 90% failures Intimal hyperplasia (scar tissue) tends to form at the outflow leading to graft occlusion Usually multiple repeated interventions are required to maintain patency Worst Place for a Catheter! Best Place for a Catheter! 2
4/17/2015 Back to the Basics Back to the Basics • History • Physical exam – Number of – Look for scars catheters – Chest wall – Last functioning – Pulses access – Veins – Which access – Edema functioned best? – Pacemaker/AICD – Anticoagulation? – Number of declots Must Look Venogram • A MUST FOR SUCCESS • Do before putting in access • Ultrasound guided access of brachial vein • Micropuncture set • Look at both sides • Must see centrally 3
4/17/2015 Forgot to Look Stay away from AICD All Too Familiar!! The HeRO Graft (Hemodialysis Reliable Outflow) HeRO bypasses central venous stenosis 4
4/17/2015 Interest in HeRO Sparked by Clinical Outcomes Central Venous Stenting HeRO Graft HeRO Graft HeRO Graft Catheter AVG CC: Recurrent Gage, et al Patency Katzman, Literature Literature EJVES JVS thrombosis of left Bacteremia 0.14 0.18 0.70 2.3 0.11 arm av graft Rates (infx/1,000da ys) HPI: 50s year old Adequacy NA NA 1.7 1.29-1.46 1.37-1.62 hispanic male with of dialysis left arm av graft. He (mean Kt/V) notes his arm has Cumulative 91% 88% 72% 37% 65% Patency been ballooned 15- 20 times, cannot Interventio 1.5 1.7 2.5 5.8 1.6-2.4 remember when n Rate stent was put in. Same problem different side Anatomy Overview 5
4/17/2015 Patient M.B. Success! September 2014 • 74 year old female • ESRD, hypertension, urostomy, colostomy, infected left thigh graft with bleeding removed • Right femoral permcath changed multiple time • She was told no further accesses possible Currently with Femoral Catheter 6
4/17/2015 HeRO outflow component in atrium 7
4/17/2015 Patient S.G. Cath lab September 2014 • Access brachial vein with • 40s micropuncture to • ESRD, CABG, HTN, DM II, left BKA, determine steal syndrome of right thigh av graft central venous patency • Left femoral permcath not functioning • US guided access well • Planning prior to • Asked to evaluate for new permcath going to the operating room Following Day in the OR Clavicle Subclavian Vein 8
4/17/2015 Subclavian vein after angioplasty 9
4/17/2015 Completion angiogram 10
4/17/2015 Patient J.H. November 2014 • 31 year old male • ESRD, hypertension, multiple previous accesses • Many permcaths • Left arm basilic vein transposition a number of years ago, now with arm and face swelling 11
4/17/2015 Tuesday 11/18/14 9AM Monday 11/17/14 6PM NOVEMBER 2014 70s year-old TDC dependent male Diabetes II and Hypertension PE in office showed dilated chest wall veins and multiple previous catheters Gore Hybrid Gore Hybrid • Upside is creating access in upper arm without having to go onto chest • Main issue is it is not early access graft 12
4/17/2015 The MOST DISRUPTIVE SUMMARY TECHNOLOGY IN DIALYSIS ACCESS RECENTLY HAS BEEN: • Always hit the reset button A. Central Venous Stening • Peritoneal dialysis may be an option • Avoid the pacemaker/AICD B. HeRO graft development 56% • Be sure to do venogram C. Early Access Grafts • Think hypercoagulable D. Biologics • Just because someone else said it 15% 15% could not be done – does not mean E. GORE Hybrid 11% 4% it is true g t s s d n t c n f i r i i e a g b n m o e r y G o l H t p S o s i s B E s l e R u e v c O o e c n A G d e V t y f l a r a l r a g E r t O n e R C e H How Old Am I? Happiness A.88 B.98 C.105 D.111 13
4/17/2015 Questions? 14
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