HeRO, Gore Hybrid DISCLOSURES Graft and Other Speaker and - - PowerPoint PPT Presentation

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HeRO, Gore Hybrid DISCLOSURES Graft and Other Speaker and - - PowerPoint PPT Presentation

Nov 15, 2023 164 likes •306 views

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)

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HeRO, Gore Hybrid Graft and Other Techniques for the No Option Patient

Stephen E. Hohmann, MD FACS Vascular Surgeon Baylor University Medical Center Dallas, Texas

DISCLOSURES

  • Speaker and consultant to Cryolife

(products include the HeRO graft)

  • Speaker for Gore (products include

dialysis access grafts and stents)

Both of these will be discussed in this presentation

It’s Almost Always the Outflow

If it were only this easy

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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

Access 101

Best Place for a Catheter!

Worst Place for a Catheter!

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Back to the Basics

  • History

– Number of catheters – Last functioning access – Which access functioned best? – Anticoagulation? – Number of declots

Back to the Basics

  • Physical exam

– Look for scars – Chest wall – Pulses – Veins – Edema – Pacemaker/AICD

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
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Forgot to Look Stay away from AICD All Too Familiar!!

The HeRO Graft (Hemodialysis Reliable Outflow)

HeRO bypasses central venous stenosis

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Clinical Outcomes

HeRO Graft Gage, et al EJVES HeRO Graft Patency HeRO Graft Katzman, JVS Catheter Literature AVG Literature Bacteremia Rates

(infx/1,000da ys)

0.14 0.18 0.70 2.3 0.11 Adequacy

  • f dialysis

(mean Kt/V)

NA NA 1.7 1.29-1.46 1.37-1.62 Cumulative Patency 91% 88% 72% 37% 65% Interventio n Rate 1.5 1.7 2.5 5.8 1.6-2.4

Interest in HeRO Sparked by Central Venous Stenting

CC: Recurrent thrombosis of left arm av graft HPI: 50s year old hispanic male with left arm av graft. He notes his arm has been ballooned 15- 20 times, cannot remember when stent was put in.

Same problem different side Anatomy Overview

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Success! Patient M.B. 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

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HeRO outflow component in atrium

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Patient S.G. September 2014

  • 40s
  • ESRD, CABG, HTN, DM II, left BKA,

steal syndrome of right thigh av graft

  • Left femoral permcath not functioning

well

  • Asked to evaluate for new permcath

Cath lab

  • Access brachial

vein with micropuncture to determine central venous patency

  • US guided access
  • Planning prior to

going to the

  • perating room

Clavicle Subclavian Vein

Following Day in the OR

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Subclavian vein after angioplasty

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4/17/2015 10 Completion angiogram

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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

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NOVEMBER 2014

70s year-old TDC dependent male Diabetes II and Hypertension PE in office showed dilated chest wall veins and multiple previous catheters

Monday 11/17/14 6PM Tuesday 11/18/14 9AM

Gore Hybrid Gore Hybrid

  • Upside is creating access in upper arm without having to go
  • nto chest
  • Main issue is it is not early access graft
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SUMMARY

  • Always hit the reset button
  • Peritoneal dialysis may be an option
  • Avoid the pacemaker/AICD
  • Be sure to do venogram
  • Think hypercoagulable
  • Just because someone else said it

could not be done – does not mean it is true

The MOST DISRUPTIVE TECHNOLOGY IN DIALYSIS ACCESS RECENTLY HAS BEEN:

  • A. Central Venous Stening
  • B. HeRO graft development
  • C. Early Access Grafts
  • D. Biologics
  • E. GORE Hybrid

C e n t r a l V e n

  • u

s S t e n i n g H e R O g r a f t d e v e l

  • p

m e n t E a r l y A c c e s s G r a f t s B i

  • l
  • g

i c s G O R E H y b r i d

56% 15% 15% 4% 11%

How Old Am I?

A.88 B.98 C.105 D.111

Happiness

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Questions?