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Challenges of the HeRO Graft & Surfacer Inside-Out Access Catheter System
Sara Stewart • Updated Feb 7, 2025 • 34 hits
The HeRO graft offers a reliable vascular access option for end-stage renal disease (ESRD) patients with challenging anatomy or otherwise limited access options. Despite its inclusion in the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and increasing use in tertiary referral centers, adoption of the HeRO graft in community practice remains limited, largely due to initial challenges with unfavorable anatomy, off-label applications, and an appreciable learning curve that may stifle long-term adoption.
Vascular surgeon Dr. Jason Wagner shares his expertise on the procedural complexities and recent technological advancements surrounding the HeRO graft, providing practical guidance for interventionalists looking to incorporate the HeRO graft and the Surfacer Inside-Out Access Catheter System into their practice. This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• Anecdotally, the HeRO graft remains underutilized in routine dialysis care, partly due to early difficulties with off-label use, unfavorable patient anatomy, and the associated learning curve during initial adoption.
• One of the HeRO graft's standout features is its ease of maintenance, particularly for declotting. Unlike traditional vascular access methods, the graft's design allows for straightforward and efficient declotting, regardless of the technique used.
• Innovations like the Surfacer Inside-Out system have significantly improved the feasibility of reestablishing access in patients with severe vascular occlusions. This technology has simplified previously challenging procedures and expanded options for patients who would have otherwise been ineligible for HeRO graft placement.
Table of Contents
(1) HeRO Grafts in Practice: Are They Underutilized?
(2) HeRO Graft Procedure Challenges
(3) Overcoming the HeRO Graft Learning Curve
HeRO Grafts in Practice: Are They Underutilized?
Though prevalent in large tertiary referral centers, the HeRO graft is still somewhat uncommon in community practice settings despite being included in the KDOQI guidelines, largely due to early challenges with unfavorable patient anatomy, off-label use, and a steep learning curve during initial adoption. These grafts are typically reserved for patients with end-stage dialysis conditions, who often have limited life expectancy or systemic factors, such as severe interdialytic hypotension, that make them unsuitable surgical candidates. However, for appropriately selected patients, HeRO grafts provide a reliable vascular access option, and their maintenance, including declotting, is notably straightforward.
[Dr. Christopher Beck]
How come we don't see more HeRO grafts? How common are they? They're in the KDOQI guidelines, right? There's a specific mention of the HeRO graft. I trained at a tertiary referral center. We saw a ton of these. I thought they were commonplace. Then when I got out into practice, every now and then, but they're like a rare bird in my scene. I just want to hear it from your side.
[Dr. Jason Wagner]
I do a ton of them, and even I am surprised by how rare I see patients with HeRO grafts. I think it's a couple of different things. I think early on, it got a bad rap, but I think people-- it's very much a learning curve. People were putting them into anatomy that wasn't actually the most favorable. People were trying to rewire subclavian lines back when people were getting subclavian things. They were kinking. They were going off IFU.
I think part of it's just simply the patient population. These aren't just end-stage renal, these are end-stage dialysis patients frequently. Their life expectancy isn't going to be as long. These are the folks where in the past, it was only that Hail Mary, okay, maybe another six months to live, but we don't want to do with a catheter. People are getting tuckered out or tired with it. I think part of it is people sometimes are able to bail out to PD. If you've run out of arterial options or you've run out of venous options, PD is growing, hormone-based dialysis is an option, there are certain things you need for patients to have.
Anatomically, obviously, I need a SVC and a jugular to get into somehow. I need arterial inflow somewhere from the arm, but the other thing you need to make sure is that they have a good systemic, consistently high enough systemic blood pressure. If someone has a systolic resting, for if they get that interdialytic hypotension that happens in a lot of dialysis patients, if they're running with a systolic of, 80 or 90 or barely 100, that's the person that's going to get to a low flow state and they might cut off their access either on the circuit or while they sleep at night.
I think, that's some of the patients that might get to the point where they would need a HeRO, might not qualify because they've got such severe interdialytic hypotension that they're not going to physiologically qualify. You can bump them up, I think probably a third of my HeRO patients currently, and every single one I've had to declot has been somebody that's had persistent hypotension. Now they're just managed with Midodrine and/or occasional Sudafed as an extra bump if they're still running low.
[Dr. Christopher Beck]
Got you. Just as an aside, if you do declots, isn't the HeRO graft the easiest thing in the world to declot?
[Dr. Jason Wagner]
It is the easiest thing to declot. Whether you're a cleaner person or a mermaid person or a suck-it-out type person with an angio cat, it's just great. It's a tube. It's like a nice elastic tube. It's great.
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HeRO Graft Procedure Challenges
The HeRO graft procedure is not without challenges, particularly in patients with severe central venous occlusions, where reestablishing access to the superior vena cava (SVC) or right atrium is often the most difficult step. Historically, severe occlusions were considered contraindications, but advances in technology, such as the Surfacer Inside-Out Access Catheter System, have transformed this aspect of the procedure, making it safer and more accessible.
[Dr. Christopher Beck]
One of the things I thought you were going to tell me was going to be: ‘the hardest part of the procedure was patients with central vascular occlusion, just reestablishing access into the SVC or to the atrium.’ What are the rate-limiting factors? I didn't hear you talk about that a lot. That is a major issue, right?
[Dr. Jason Wagner]
Yes. That is a major issue that used to be an absolute, either contraindication or major like the biggest hurdle. Right. You got to get that outflow. I used to think of it as like this impossible feat. People like doing the crazy aggressive, RF, recanalization, et cetera. The nice thing is, technology and industry has evolved to meet this need. Really bluegrass and now mirrored onto technology and has helped make it safe and available throughout the US.
The Surfacer, it's great. I was part of that first group that was at the FDA, IFU training down in Houston. Honestly, it felt like being one of the cavemen hanging out with the people, the first caveman that created fire. This is warm. This is great. You can make this. It's like you can make it so I can just always pop back into the right IJ or create a new right IJ and just pull in either a TDC or eventually a HeRO. They're like, yes. I thought the first three or four patients that they were going to demo it on or going to try it on, were going to be these chip shots, just a focal little IJ equipment.
[Dr. Christopher Beck]
Two centimeters.
[Dr. Jason Wagner]
These are some severe relatively long segments, either jugular occlusions or SVC occlusions. One guy even had a trach. It was some very aggressive stuff and it was just--obviously, these are the surgeons that have been doing and the interventionists have been doing it as part of the safety trial. It was just awesome. With that, it was like, all right, cool. Aside from arterial insufficiency, I God willing will never have to go below the waist ever again for an access. If I can surface or somebody and I can pull in a TDC, that person can get a right-sided HeRO.
Overcoming the HeRO Graft Learning Curve
New Surfacer and HeRO graft users tend to describe a learning curve with these tools, which can require proficiency with advanced vascular access techniques to overcome. While the Surfacer system is designed to be intuitive, it is recommended that new operators start with less complex cases, avoid tackling challenging occlusions during initial procedures, and utilize mandatory proctoring to ensure safe and successful outcomes. Similarly, successful HeRO graft placement can be technically demanding, requiring careful attention to avoid kinking at the graft-to-connector interface, addressing fibrin sheaths or stenosis in venous outflow, and managing hypotensive patients through appropriate pre-procedural planning.
[Dr. Christopher Beck]
We're coming up on our hour. We got a little bit of time left, but if you have any final thoughts, whether it's about the HeRO graft or the Surfacer, what would you want--? We have a big IR audience, we have some vascular surgery people, interventional cardiology, what are final thoughts either with the HeRO graft or the Surfacer when it comes to the dialysis circuit?
[Dr. Jason Wagner]
With Surfacer, it's great. There is definitely a learning curve with it.
[Dr. Christopher Beck]
How many cases of learning curve?
[Dr. Jason Wagner]
I think probably two or three.
[Dr. Christopher Beck]
All right.
[Dr. Jason Wagner]
It's not crazy, but I think that if you're going for the chip shot, easier cases, if you're going for the really big, hardcore, aggressive half the SVC is out, I would not do that in the first half dozen cases. I would definitely not do that outside of a hospital where you have cardiac surgery as a backup. I have a friend in Pennsylvania who did a case, got a couple of easy ones under the belt, and swung for the fences. Everything went great until they took a picture and they're like, "We just lost the art line." This wasn't my case, but he was telling it to me at a meeting. He's like, "We lost the art line." He's like, "That's weird."
They had an art line in the right arm, in the right radial, and they take a picture, and sure enough, they skewered through the subclavian artery right at its junction. They fixed it with a stent graft and it ended up actually all being fine-ish. I'm a big fan of the Einstein approach of, a smart man learns from his mistakes, but a genius learns from the mistakes of others.
[Dr. Christopher Beck]
Right. Thanks for sharing.
[Dr. Jason Wagner]
That's something that I will also be very wary or careful of and make sure I'm perfectly oriented. They're going to have proctoring, it's a mandatory thing for the first couple of cases.
[Dr. Christopher Beck]
Cool.
[Dr. Jason Wagner]
Take advantage of Merit's opportunity for proctoring for that. It's great, it's accessible technology. There's nothing unintuitive about it. It's all completely intuitive approach as far as how you're going to orient it, how you're going to look, all the different steps. Basically, just colored by numbers. If you do all of the steps appropriately, there's an extremely high probability of success, and most importantly, of safety.
With Surfacer, it's just strictly state of the eye of you. You're going to be fine. Start with the easy cases. With regards to the HeRO, the biggest thing is making sure that whatever you're using is your outflow. Say if you're rewiring a TDC, make sure that there's no fiber and sheath before you dunk your venous outflow component into it. Make sure that there's no kink at the graft to titanium connector area that's laying nice and smoothly. It's not like an abrupt angle change as you tunnel it because that's an area where I've seen-- I've had an issue once in the past and I've had some partners with issues there with their patients.
The most important thing for HeRO is make sure that the patients aren't hypotensive at any time or particularly if they're in an interdialytic hypotension where they're constantly running in a systolic under 110. My personal cutoff is if a patient walks into clinic and there's somebody that we're going to be teeing up or if I have a patient that I'm already teeing up in my mind that's going to be a HeRO patient, that's somebody where I'm having the nurse check blood pressure in both arms.
I've had one patient where they had a left subclavian occlusion. Their systolic was 80 on that side, but it was 150 in the target arm, and it's like, all right, cool. For the record, you're going to have to get your blood pressure checked in your leg or somewhere else because your left arm is not accurate anymore and you're not obviously going to blood pressure cuff on your graft anymore. Watch out for the hypotensive patient.
[Dr. Christopher Beck]
All right. One more question. Even though I said that was like final thoughts, resources. If people want to learn more either about the HeRO graft, whether it's the nuts and bolts of it or the Surfacer, can you give them if someone's like, "Oh my God, I've never heard of this stuff," where would you send somebody or even trainees?
[Dr. Jason Wagner]
I'm hoping that most major, at least in the Dialysis Belt of America in the Southeast, I'm hoping that all the big academic centers are routinely using it or occasionally using HeRO. With regards to the HeRO, I gladly proctor cases for Merritt Medical. I know there are several other physicians that will gladly travel and proctor.
I think going back to your question as far as why we're not seeing more of them, I think people are wary of it because it's all these big catheters, these tubes, these things, all these steps. It's a 45-minute case when it's done correctly and efficiently and smoothly, maybe an hour and 15, but it's not a-- once the catheter's in, then it's just sewing a graft on and you're skipping anastomosis, so it's not that bad.
Getting somebody that can proctor a case, Merritt has a very good team of proctors, both on the clinical, on their actual employee side, but also physicians are able to go and help out and be there to observe and guide surgeons.
Obviously, they have a ton of resources on their website. They're putting together a ThinkVascularAccess course that'll be sometime in the spring of 2024 that's going to focus on Surfacer, HeRO, peritoneal dialysis, and other vascular access maintenance and management stuff. It's going to be a three-in-one or four-in-one half-weekend or weekend course at the VASA, the Vascular Access Society of the Americas Biennial Practicum, which is like every other year, they have a skills lab. Then I think even the CETA meeting, they have a skills lab.
If you target dialysis meetings, more often than not, the day before or the day after the meeting, there is a skills lab or educational thing as part of it. People are welcome to come down to Sarasota and hang out with me anytime I've got one going on, as long as the hospital will approve it.
[Dr. Christopher Beck]
Does that happen? People come down and watch you in the lab?
[Dr. Jason Wagner] I've had probably about five, six folks come down over the past year and a half to see-- some just have driven, some have flown, but to come down and just see how do we do it and just also just setting up the room, just like little nuanced things.
[Dr. Christopher Beck]
Yes, of course.
[Dr. Jason Wagner]
That make it a little bit easier. Even just with your OR team, if you're going to really start going into the, let's say, the rare air or the murky water of end-stage dialysis stuff, it's going to be, you want to make sure you have a consistent OR team, be it whoever your first assist is, whoever your scrub tech is, especially with HeRO and the hybrid suite or an OR with the CRM, like you want people to know the parts, how to prep them so you're not trying to do the cut down, but also make sure they're not messing up stuff on the back table.
[Dr. Christopher Beck]
Thinking about that part, right.
[Dr. Jason Wagner]
There are tons of resources to when you could do your first case at your hospital, the merit of being proctors or reps will easily be able to help educate and in-service the staff very quickly on it.
[Dr. Christopher Beck]
Just going back to people going to your lab and, for all the docs out there, I think it's commendable for people that take the time to show people the cases, and also commendable, think about docs who are like flying across the country to like see someone else do a case and walk them through that. I think that's commendable on both fronts.
[Dr. Jason Wagner]
For me, the only way I learned how to do anything that I can do is because I either was forced to take the time when I was in training or I chose to take the time after training to go and learn stuff. When I was fortunate enough to go do that first round of folks to train on the Surfacer, it was like one of the things, yes, I'm going to do this thing. It looks pretty cool on paper. I don't know. Then you see it done the first time and you're just like, "Wow, that's awesome. I want to do that."
[Dr. Christopher Beck]
I think we just got the hook for the podcast. To the audience, thank you for listening. If you like the show but want more, check out the show notes of this episode. Those can be found at www.backtable.com. Special thanks to the BackTable team, a lot of med students who make that happen for us. For others interested in supporting the show, like, subscribe, or share this podcast on social media, or just forget social media, just go old school, tell somebody about it. Old-fashion word of mouth talking to another human is really helpful as we continue to build this community. That wraps things up. We'll see you next time on the BackTable podcast. Dr. Jason Wagner, thanks for coming on, man. Appreciate it.
[Dr. Jason Wagner]
Thanks for having me. It's been awesome.
Podcast Contributors
Dr. Jason Wagner
Dr. Jason Wagner is a practicing vascular surgeon in Sarasota, Florida.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2024, February 6). Ep. 414 – HeRO Grafts in Dialysis: Techniques, Challenges & Solutions [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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