‘The HeRO Graft’ An option for patients with End Stage Vascular Access Mr. James Gilbert Consultant Transplant & Access Surgeon
Disclosures I have the following potential conflicts of interest to report: I currently hold a consultancy contract with Merit Medical and am paid for any work undertaken. I have received Honoraria from Getinge Maquet
• Good Pump Speeds • Normal Pressures • Process good volumes • Excellent Adequacy
Consuming the ‘venous capital’ RRT journey - 2 or more lines (tunneled) - 3 or more fistulae - AV Graft(s) - 1-2 Transplants An increasing access challenge Especially if develop CVS / CVO
End Stage Vascular Access ‘End stage access is reached when all autologous vein options and conventional graft and catheter placements have been exhausted or are not possible and there is the presence of central vein pathology’ (Gilbert VASBI 2014)
Venous Hypertension
What could we do? Leave them on a line (wherever we can place one) Consider a ‘Heroic Intervention’ Any procedure or intervention that seeks to treat or bypass Central Venous Pathology (CVP) to enable: - Autologous access or grafts to function - Treatment / prevention of venous hypertension
Heroic Options: Use of Lower Limbs Angioplasty / Stenting CVS Atypical / Exotic access / bypass procedures HeRO graft Insertion Surfacer Inside Out Catheter System
Hemodialysis Reliable Outflow (HeRO) ▪ Treatment option for ESVA patients ▪ Only fully subcutaneous AV access option that offers long term access in CVS ▪ Option for patients with failing AVF or graft due to CVS ▪ Option for the catheter dependent or approaching catheter dependence patient with CVS
HeRO is a 2 Component Device
Venous Outflow Component Braided Nitinol stent Covered with Silicon Kink Resistant Crush Resistant “ HeRO is a Customizable, Sizeable REMOVABLE stent”
Arterial Venous Graft Outflow Component Component
3 TCC’s in 3 years! • 3 AVF attempts, Right B/C AVF eventually successful • 18 months venous hypertension (arm, face, tongue, vocal cords!) • Home Haemo patient, agrophobia, wants to stay that way!
• Left IJ HeRO • Necklaced across to right side • Joined onto Right B/C AVF • Maintained needling areas • Instant symptom relief
Clinical Outcomes HeRO Graft Oxford 0 NA 84.6 % 1.125
Make your own with Super HeRO • Super HeRO Adaptor first product of its kind in vascular surgery • Coupling device that allows for certain grafts to be used with HeRO Outflow Component • Avoids graft to graft anastomosis Adapter
Closing Comments ESVA patients increasingly more common Any history / presence of a TCC accelerates ESVA due to Central Vein Stenosis / Occlusion The HeRO Graft is the only AV access option that can bypass CVS and provide reliable dialysis The Super HeRO adaptor enables direct connection of certain grafts with the outflow and avoids a graft – graft anastomosis or bridging catheter
james.gilbert@ouh.nhs.uk
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