The HeRO Graft: A Solution for End-Stage Vascular Access

[Dr. Christopher Beck]
There are approximately 700,000 patients in the United States being treated for end-stage renal disease or ESRD due to kidney failure. Globally, the incidence of new ESRD cases continues to grow at an aggressive annual rate. To stay alive, patients with ESRD will require either a kidney transplant or some form of kidney replacement therapy to remove toxins from the blood, namely hemodialysis or peritoneal dialysis.

Patients on hemodialysis require vascular access for treatment. Most patients start with a long-term hemodialysis catheter but can have multiple catheters placed throughout their hemodialysis journey. Over time, patients can experience blockages in their central venous system due to repeat catheter placements. This challenge will require healthcare providers to seek less optimal access locations near the groin, which are prone to infection and are uncomfortable for patients during frequent hemodialysis treatments.

The HeRO graft may be an access alternative for patients who are catheter-dependent or approaching catheter dependency. The system is fully subcutaneous, resulting in lower rates of infection. It can also be placed in the upper extremities, making hemodialysis treatments more comfortable for patients. Dr. Wagner will explain why the HeRO graft may be an access alternative for hemodialysis patients and how he utilizes this unique vascular access system in his practice.

[Dr. Jason Wagner]
The best way I can describe a HeRO, it stands for Hemodialysis Reliable Outflow. The idea of reliable outflow hemodialysis, some would say that's a misnomer. It's like a never event, it's not a thing. With HeRO, it is. The best way to describe it and the way I tell my patients, I say, "Think back to like the '60s or the '70s or whatever they last manufactured the El Camino. It's a pickup truck in the back and it's a car in the front. It's like a pickup car."

The HeRO, it's a graft by the arterial anastomosis. It's a graft up the arm, but then instead of plugging into the vein, it clicks in with a very sleek titanium connector into what basically is a 20 French stent that's embedded inside of a silastic, like a silicone tube. Basically, it's the best aspects of both a graft where it could be inserted quickly and used quickly. It's a suture arterial anastomosis, but then you're skipping beyond the entire axillary and subclavian segment, and pry straight to the jugular and straight down to the SVC and the caper atrial junction.

The nice thing is you're getting a good large bore catheter for your outflow, and you have a graft component immediately available to be cannulated in a couple of weeks if you're using a standard graft or if you use the Super HeRO, which is even better branding.

[Dr. Christopher Beck]
Oh, man. I haven't heard of the Super HeRO. It's so good.

[Dr. Jason Wagner]
Super HeRO is great. It's just like a regular HeRO, just more powerful. It was raised on Krypton. The Super HeRO is the regular HeRO outflow component, but instead of having a graft that's already pre-connected to a little titanium coupler quick disconnect click-in thing that goes into the silastic tube, it's the thing that joins the silastic tube to a pressure fitting onto a different type of graft.

If you, for instance, needed to revise a graft and plug into it, or if you needed to-- somebody's only access was a right IJTDC or a left IJTDC, you would simply rewire that, you cut down on the neck, rewire it, drop your central venous component, put it where you want it to be, tunnel out the distal component to the deltoid pectoral group in the shoulder, and then you're going to basically hook this little pressure clamp connector onto the tube, onto the venous outflow component, and then you basically just slide the graft overlying the other end and the friction thing clicks into place.

You can hook up a Gore AcuSeal or a Flixene, and the benefit there is you can take somebody who has no other access, you take out their TDC, you put in this thing, sew in the graft, and you have an immediate access or early cannulation graft ready to be used right away. I've had patients that we've literally sent from the OR to the dialysis unit, and sometimes we even access them in the OR with their dialysis needles, take everything down sterile, and then send them to the dialysis unit.

Ideally, we just dialyze them beforehand, give them a day or two off, and then stick them in the graft, but it's nice because a lot of people used to have to just take the regular HeRO, cut off the majority of the graft portion, then sew on an immediate access graft. It's one additional anastomosis, extra time, a waste of a graft component. They've figured, a lot of people are doing this, let's make some things that meet the need. I think a couple years ago they came out with it, and it's very slick.