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BackTable / VI / Podcast / Transcript #414
Podcast Transcript: HeRO Grafts in Dialysis: Techniques, Challenges & Solutions
with Dr. Jason Wagner
In this episode, host Dr. Chris Beck interviews Dr. Jason Wagner about his experience with the Hemodialysis Reliable Outflow (HeRO) graft and the Surfacer system for treating patients with end stage renal disease (ESRD) and limited vascular access options. Dr. Wagner is a practicing vascular surgeon in Sarasota, Florida. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) ESRD in the US: A Growing Problem
(2) Who Is the End-Stage Vascular Access Patient?
(3) What is the HeRO Graft?
(4) What Patients Benefit from the HeRO Graft?
(5) HeRO Graft Procedure Guide
(6) The Prevalence of HeRO Grafts in Practice
(7) HeRO Graft Challenges
(8) What is the Surfacer Inside-Out Access Catheter System?
(9) The HeRO Graft & Surfacer Catheter System Learning Curve
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(1) ESRD in the US: A Growing Problem
[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.
Now, back to the show. Today, our topic is regarding access for dialysis options of end-stage vascular access. To help us with this discussion, we have Dr. Jason Wagner. Jason is a vascular surgeon based out of Sarasota, Florida. Jason, welcome to the show.
[Dr. Jason Wagner]
Thanks for having me. I appreciate it. It's good to be here.
[Dr. Christopher Beck] Hey, just an icebreaker, will you tell us a little bit about your training, your practice as it stands right now?
[Dr. Jason Wagner] Yes. I grew up in Virginia Beach, Virginia. When I was in medical school, I was at Eastern Virginia Medical School, so EVMS, which at the time I did not realize was such a major research and volume hub for dialysis access.
[Dr. Christopher Beck]
You were just oblivious to all of what was going on?
[Dr. Jason Wagner]
I was like, "Oh, man, I guess everyone's on dialysis here." It turns out, no, it was just they had 20-plus vascular surgeons and some transplant surgeons just doing a ton of it. It wasn't until I was later in med school at residency when some of the devices that I thought were just commonplace, be it immediate access grafts or HeRO, I thought everybody had been exposed to them for years. No, it's just that I saw them first or very early on when I was at EVMS.
I graduated from EVMS, went to do an integrated vascular surgery residency and fellowship combination at UPMC in Pittsburgh. Again, a huge vascular access, huge tertiary referral center and encatchment area. There, saw not just the bread and butter, but a lot of moldy bread and rancid butter.
[Dr. Christopher Beck]
I haven't heard that a lot. That's good.
[Dr. Jason Wagner]
I saw a ton of it. Then that obviously, during our two research years, we ended up doing either basic research. I was allergic to all the different lab rats and animals in the lab. It was very evident early on that I was going to do clinical research.
[Dr. Christopher Beck]
Cool.
[Dr. Jason Wagner]
If you're on the clinical research track as part of the T32 grant from the NIH, you do Master's in clinical research methodology. My clinical research focus was dialysis access-related. Looking at large database, data mining, USRDS, and then also prospective retrospective studies of immediate access grafts and HeRO grafts.
[Dr. Christopher Beck]
Let me ask you this, you finished up your integrated residency fellowship, how long have you been out and what does the practice look for you now? Is it like private practice?
[Dr. Jason Wagner]
Great question. I'm in a very classical model private practice. I'm five years out now. Loving every minute of it. Getting to both learn and grow in the role of being a small business owner, but then also having the flexibility access to an OBL, access to also outpatient labs, things like that, and then obviously, ORs all over town.
[Dr. Christopher Beck]
Nice.
[Dr. Jason Wagner]
The biggest change for me in Virginia, in Virginia Beach, in Norfolk, Virginia, there's a decent amount of patients of varying ages and varying body habitus. In Pittsburgh, it's skewed a little younger, but also heavier. I think anyone over the age of 80, they just wrap them in a bubble wrap and ship them either to Arizona or to Florida. Then when I moved down to Florida, I figured out where all those people ended up. I have the healthiest, they're end stage renal but I still have the healthiest 90-year-olds or the sickest 35-year-olds.
[Dr. Christopher Beck]
Wow.
[Dr. Jason Wagner]
Learning how to care for the nonagenerian as a functional human has been a-- dialysis has been an interesting skewer learning experience early on.
[Dr. Christopher Beck]
Cool. Very good practice. A couple more questions about the practice. How many docs are in the group? Is it all vascular surgeons, do you all have cross-specialty, anything like that?
[Dr. Jason Wagner]
Yes. Six of us are operative. We have one additional surgeon who used to operate, but now is just doing clinic and seeing patients in clinic. We have a nice pure soul specialty. It's in the specialty of vascular surgery issues. I'm the only person in our group that does peritoneal dialysis. I'm the only one doing laparoscopic procedures, but just general vascular practice. I skew a little bit heavier balance-wise to dialysis, but still doing aortic, deep vein, et cetera.
[Dr. Christopher Beck]
All right. I set the stage for end-stage vascular access, but really, the podcast I'm trying to drill down on, and we'll try and cut out some of the fluff, but we want to talk about the HeRO graft. Without just launching into the HeRO graft, will you talk about end-stage vascular access and how you think about that patient population?
(2) Who Is the End-Stage Vascular Access Patient?
[Dr. Jason Wagner]
Yes. When it comes to end-stage vascular access patient, it's a lot of-- I break it down into-- it's the same thing with anything vascular access, it's going to be inflow and outflow. I have patients that are end-stage vascular access, not because of any venous outflow issues, but purely because of arterial, have severe peripheral arterial disease or diabetic vascular disease or end-stage renal disease combination with the arterial calcifications associated with that. Then on top of that, diabetes or PED and a smoking history, it's that patient population.
Those are the ones that are actually, I think, probably the hardest to manage because I could figure out some creative outflow 99% of the time. If I don't have a way to plug an inflow in any way, then that's the person that's going to end up with a graft south of the horizon on their leg, or it's going to be somebody who I'm going to be having catheter dependent, or I might try and coax them into bailing out towards peritoneal dialysis to get them off of the need for arterial inflow. That's the arterial side of it.
On the venous side, especially in Sarasota, I have patients that have been on dialysis for 15, 20, 25 years. If you look at their arms, it's almost like on a tree, you can count the rings. I can count the rings of how many-- there was your brachycephalic, okay, there was your brachiobasilic, there was your first graft, there was your second graft, there was your third graft. That's not even counting the forearm, that's just upper arm.
I think with that, we're talking people that have had numerous interventions, and so need to get creative. Are you going to jump centrally and do a HeRO, or are you going to try and do a sutureless venous re-anastomosis? I have a procedure I like to do, I call it the Phoenix procedure. Just basically takes where he's had a chronically down graft that someone's abandoned, usually elsewhere. They've now, they're either snowboarding, they've come to Sarasota. They're like, Oh, yes. My graft shut down two, three months ago. They gave me a catheter and I came down here for the winter."
If they've had a ton of other options and on ultrasound, it looks like everything's open just beyond the anastomosis, I might take him to the OR, do an open thrombectomy, cut down and try to recanalize the outflow, small little covered stent across the area of disease, the venous anastomosis. Then I'll pull the arterial plug and they'll be up and running and it'll be cannulated that afternoon or the next day. I call it a Phoenix procedure just because like raising it from the ashes.
[Dr. Christopher Beck]
I like that.
[Dr. Jason Wagner]
I try and first, I guess, make the most of what I have before I have to put anything else into them. The nice thing is when it comes to-- in the past like 5, 10 years between HeRO and Surfacer, being able to reestablish central venous access either as a way to just take a catheter in so you get a catheter out of a leg or to get a HeRO in has been huge.
[Dr. Christopher Beck]
Let's tackle-- because you talked about the two devices I really want to touch on, advanced tools to handle patients with limited vascular access options. I want to talk about the HeRO first. First, what does it stand for? For people who haven't seen it or aren't familiar with it, we have plenty of trainees out there, will you just give it a high-level overview of what exactly the HeRO graft is?
(3) What is the HeRO Graft?
[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 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 border 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.
(4) What Patients Benefit from the HeRO Graft?
[Dr. Christopher Beck]
All right, Super HeRO, like it. Talking about the HeRO, seems very nice. What patient population is this for? When do you get to where you start considering having a patient for a HeRO graft?
[Dr. Jason Wagner]
If I have a way to-- and I see, if someone has-- they burn up both arms as far as axillary veins, brachial veins. If you're looking to have to basically be doing an axillary artery and vein cut down in the infraclavicular space to get your inflow and outflow, that's somebody where if I'm having to go that high up the arm to get a venous outflow, that's a pretty morbid thing. I always think, what's the worst thing that could happen to someone with dialysis access, aside from just unmanaged or mitigated steel where they get an ischemic extremity, it's going to be, God forbid, it gets infected.
In vascular surgery, and I'm sure in IR, you're always thinking, what's the next? You're not just preparing for this surgery, but what's the next one after that? I always think, okay, how much is this going to suck to take out if it's infected? I've done cases back in training where we've done axillary cut-downs to get our venous outflow because everything in the arm was just inaccessible or it was all scarred down. When those got infected, or if a stent was in that area, you had to take out an infected stent graft, that's a really morbid operation and you're worried about brachial plexus issues, et cetera.
The nice thing about the HeRO is you're just going straight to the jug. If it's open, you can get a wire through it, you can balloon it up and get the central venous outflow to basically the catheter component in. You've got your outflow, you can connect that any way you want, tell it how you need to get the graft connected to it. For my patients that have had-- actually, going back to the people I do the most Heroes on, I'm actually using it to revise persistent or recalcitrant outflow issues in that proximal brachial to axillary to subclavian region.
I balloon, I put a couple of stents in, it keeps coming back or going down, but their fistula, be it a brachiocephalic or a brachiobasilic, is still open and if you just have massive arm swelling from the central venous occlusion or stenosis, that's someone where I can do a traditional HeRO and I'll just take the outflow portion of their patent fistula or graft and sew it onto the HeRO. Then I've established them a durable means of outflow. I'm probably using it just as much, if not more, for access revisions of a patent access or recently occluded graft as I am for a de novo or a new HeRO placement.
[Dr. Christopher Beck]
One of the questions, and I don't know if it goes without saying, but basically, it's all upper extremity work. The HeRO in your algorithm would always come before any access, like in the leg or the thigh, right?
[Dr. Jason Wagner]
Yes. For me, I will go to the ends of-- I have so many patients, and I'm a nephrologist too. I will go to the ends of the earth to keep a dialysis access above a waistline. I'd probably say it's probably once a month I have to take out an infected femoral loop graft on somebody. It's usually it's come in from out of state or out of our encatchment area here in Sarasota. Those are the people that are then, do the history, do an upper extremity venogram.
Sure enough, yes, that's the person that their next access is going to be maybe take their femoral TDC that they have, convert it, and service them back to an IJ line, put an IJ tunneled line in for a couple of weeks, and then convert that to a HeRO, or just take them straight to HeRO on one side or the other. Going back to your question earlier, as far as other patients I consider it for, aside from the upper extremity revisions, it's also for central venous seclusion disease, it's also going to be the folks that have known strictures with pacemakers and a focal occlusion right there.
It's like, I'm not going to-- say they've had an infection in their left arm, they've got a right-sided pacemaker, they have a focally occluded on venogram or on ultrasound subclavian where the pacers are. I'm not going to try and recanalize that. I'm not going to create an access distal to that knowing it's going to either shut down because of outflow problems or cause severe immediate arm swelling.
That's somebody that I'm going to say, "Okay, look, here are our options. Your jugular is open. I can bypass around your pacer wires by going to your jugular and down to your SVC that way, and I can get them a good durable access that will work the first time, as opposed to see if it takes fistula or the-- and more often than not, they'll work, but they're just going to get massive arm swelling and then the morbidity of that is just terrible.
[Dr. Christopher Beck]
I guess my next question is, how exactly do you do the procedure? If I had to guess, the hardest part of the procedure is working out how you're going to get the catheter side of the catheter in the atrium. I just want to hear about the process of actually putting in a HeRO graft, and then we can actually dig into the advanced stuff, which I think will segue us into the Surfacer. Just tell me, how do you put in the HeRO graft?
(5) HeRO Graft Procedure Guide
[Dr. Jason Wagner]
The first thing is getting that central venous access because if I can't get the catheter in you-- I want to make sure I've identified a good arterial target for my anastomosis. If it's going to be cutting down on an old graft near the distal upper arm and my plan is to use that as my inflow and just pull the arterial plug so I'm not having to manipulate the brachial artery anymore, or if I'm just doing a new brachial artery anastomosis, identify that on ultrasound first. I know where I'm going to be, cutting down or getting arterial inflow.
Then the next thing is going to be just making sure I can get into the SVC. If they already have a tunneled catheter ipsilateral to it on the same side, I'm not as worried about it because I know I've got at least 14 or 15 French hole to-- maybe I need to expand it a little with a balloon or dilate it serially, but I know I've got a channel to the SVC there. That's going to be my first thing.
If they've got a tunneled catheter in place, my usual thing will be I'll cut down on that at the neck, at the venotomy, take the catheter out, plug it with usually a 10 or 15 French sheath just to keep a channel there. Then I'll cut down on the arm, get my arterial inflow, make sure it's okay. Once I've got those inflow and outflow at least roughly established, I'll make my third incision at the deltoid pectoral groove, in the anterior medial shoulder.
Then from there, I'll work on getting my venous outflow component into place. I have a stiff wire, usually either a straight Lundy or a Meyer wire or implants, always straight down. I'll confirm it. I always save a picture to make the malpractice gods happy of it going from the neck, all the way through the cavoatrial junction, down into the IVC distally. It's a nice, good, strong rail for which to do serial dilatation over or if I need to balloon it, if there's a bit of a stricture or fibrin sheath from a prior catheter being there for a while.
If I can get my, HeRO tear-away dilator sheath into position, which is it's a 20 French, it's a pretty good-sized thing. If I can get it into position and get it down, then from that, you basically advance the venous outflow component over its removable dilator and stylet, which is then over the stiff wire. Your trick is you got to use sterile water-based lube, get it lubricious as they say, and then basically slide it in.
The big thing is, years ago, people used to have problems with it where the tear-away sheath would wrinkle or crinkle. They've fixed that over the past couple of years. I think they've revised it I think two times since. That's been really nice because that to me is always the most stressful part of the procedure is just making sure the sheath doesn't tear or break. Now they're very reliable, which is great. It adds to the reliable aspect of it. It's a very reliable tear-away sheath now, which is surprisingly a silly thing to be really excited about, but it's awesome.
Once you get your venous outflow in, then I usually hook up like a little Christmas tree, step dilator syringe, inject some half and half contrast, see where my tip is roughly. I want to get it right at the top of the cavoatrial junction to make sure that there's no residual fibrin sheath, especially if they've had a prior TDC there. If they've had a ton of tunnel catheters, sometimes what I'll do is I'll just take a quick picture from above versus through that placeholder sheath to make sure there's no fibrin sheath. I'll have done that.
If I see that there, then sometimes I'll either stick it, take the jugular a second time so I'm not in the fibrin sheath, or I'll balloon disrupt it first because even though this thing says reliable outflow, I don't want to be setting it up for failure by plugging a thing into a digital little like–
[Dr. Christopher Beck]
Sticking it into an old dirty sock.
[Dr. Jason Wagner]
Once it's in, it's in a good spot, I'll mark the screen, figure out-- I feel like all my patients have had sternotomy. There's a sternal wire or a rib I can mark it against. I save a picture so I know roughly on the screen regarding some anatomic landmarks. I'm doing these either most over at a hybrid suite. Sometimes they're with a C-arm, but I'll usually just save an antoic mark as to where the tip of that catheter is, the venous outflow component.
The nice thing, it's got a nice radio pick band on it. It's easy to figure out where it is. I'll put it in right there and then lock it with heparinized saline. There's a very nice plastic clamp that comes with it that's catheter or venous outflow component tube safe. I click that right at the venotomy, right at the neck where the cut-down incision is because that way I know it's not going to go any further. If it's come back at all, I know I can push it back to that level and it's going to be roughly at the right spot.
This one, I've removed my wire and the dilator from it. It's just the catheter in the SVC. At this point, I will take usually a aortic clamp or the epigastric clamp and I'll tunnel from the delta pectoral groove to the incision in the supraclavicular incision at the base of the neck. I'll cut the end of the venous outflow component because there's this little silicone little handle on it. You cut that off. You grab the functional, the distal end or what will be the flow proximal end or the parts that stick out of the body. You pull it through. I, again, flush it, make sure it's in good position, make sure my outflow spot is where I want it to be.
At this point, I'll have already exposed the brachial artery or whatever the arterial inflow is going to be. I'll figure out the course that I want to tunnel in the upper arm to make it easier for cannulation. Then I will tunnel from the arterial anastomosis up to the delta pectoral groove where the venous outflow component is now coming out. This is tunneled. I will then pull the graft component through from the shoulder down towards the elbow.
At this point, you've got the titanium click connector part that's built into the graft with the flexible external support, like a spring basically, around it to prevent kinking at that graft metal junction. Then I will overlay that just at the skin to figure out exactly where I want to cut the venous outflow component to end up. At this point, I'll cut the venous outflow component, put the graft onto it, and I don't pull the graft all the way in or all the way down and flush because this way, you get more laxity in the graft because you can put on the pressure connector, the pressure fitting.
Then once it's secured into place, and basically, all you're doing is it's like a finger trap. You're just squishing it in. As you pull against it, it tightens up against it. I've done that, again, spot check with the clamp at the neck that the venous outflow component hasn't moved at all. Then with a little bit of tension on that, I'll just pull the graft taut so that it's a nice smooth course. It pulls everything under the skin.
Then at this point, my outflow is temporarily clamped and it's hep-locked at the neck. No blood or anything in the graft or in the distal part of the venous outflow component. Now it's just pull up on the artery. I like to locally heparinize. I'm not a huge systemic heparanization person if I don't have to, especially with all the tunneling that can just get big hematomas. I'll pull up on the artery, each end, arteriotomy, the standard running anastomosis. Effectively, the graft in here will end up clinking at the neck. Before it flushes the artery, boom, tie it down, and then you're going to have a thrill and brewery and it's going to be great.
The nice thing is because it's a pretty long conduit on the outflow, you can make a decent-sized arterial anastomosis, six, seven millimeters. Because of the outflow resistance of the longer circuit, you're not going to be a huge setup for steel, but obviously, still check the distal perfusion of the hand.
[Dr. Christopher Beck]
Once it's in, how long before it can be used as a standard graft?
[Dr. Jason Wagner]
Yes, standard graft. You can do it as early as two weeks. Most of my patients, we'll tell them two weeks and they'll beg and plead to either make it two and a half or three. The big thing is if you're going to do it sooner, either switch to using a Super HeRO and an immediate access graft or the cannulation graft as the cannulation segment or just make sure that there's really meticulous hemostasis being applied a couple of weeks out.
(6) The Prevalence of HeRO Grafts in Practice
[Dr. Christopher Beck]
I guess my question is this, how come we don't see more HeRO grafts? How common are they? They're in the Kedoku guidelines, right? There's a specific mention, very 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, I still 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.
(7) HeRO Graft Challenges
[Dr. Christopher Beck]
Yes, it is great. All right. That's just an aside for people who want to geek out a little bit about the HeRO graft. All right. I guess I thought we would actually get into it more. 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 collusion that just reestablishing access into the SVC or to the atrium was going to be like, 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 shot, just a focal little IJ equipment.
[Dr. Christopher Beck]
Two centimeter.
[Dr. Jason Wagner]
These are some severe relatively long segment, 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 it a TDC, that person can get a right-sided HeRO.
(8) What is the Surfacer Inside-Out Access Catheter System?
[Dr. Christopher Beck]
Okay. It's game on for CVOs. Before you get too far into it, will you just tell the audience, what is a Surfacer? What are the components of this? Why do you like it? Go ahead.
[Dr. Jason Wagner]
The Surfacer is, imagine someone took-- there's the movie, Honey, I Shrunk the Kids, right?
[Dr. Christopher Beck]
Now we're really dating ourselves here. Early Rick Moranis.
[Dr. Jason Wagner]
Yes. Early Rick Moranis is everything seems really big. I think there was a sequel or a secondary sequel, Honey, I Blew Up the Kid. It's like a Honey, I Blew Up the Kid. It's basically a dial-able curvilinear needle guide that you will use fluoroscopic landmarks and fluoroscopic targeting to basically direct the needle guide out. Then you have a step-advanceable needle wire that is a super sharp tipped wire that you'll advance through this curved needle guide directed towards a very, very fancy polished stainless steel washer that you're taping at your target exit site on the skin and you basically line it up.
Then once you're lined up and oriented and you've done a two-view to confirm you're appropriately oriented, you're basically accessing from the right femoral coming up. The steps are coming up from the right groin, you're rewiring a femoral TDC or just a fresh access. You're coming up the right groin, up your iliac vein, up to the IVC to SVC. You basically are going to first go through this with a glide wire to catheter to get it as distal as you can.
Then you put a stiffer wire there to guide your support sheath up, then you're going to guide your HeRO device, your Surfacer device up to this position. Then you're going to have your targeting disc, which is basically a washer that's taken a position at the skin, and you're going to look down the barrel of the washer to the orienting function like crosshairs are opening in the tip of the surfacer.
Through this, you're going to advance your curved needle guide out, and it's a sharpish hollow tube on a curve, like a pioneer. Then you're going to just advance a needle wire. Basically, it's a wire that's super sharp, straight up through that, and that will tint the skin or poke through the hole. Ideally, if everything's just right, you'll get the bullseye and you'll poke through, and you're just happy if it just comes out adjacent to it or near it.
Then a couple more advances, then you've got the needle wire sticking out of the skin, so it's inside-out, hence inside-out surfacer. Then you'll advance a little more wire, and then basically what you're going to do is you're going to make a small nick in the skin, and you will actually pull in a tear-away sheath at this level. Instead of pushing and kinking, you're simply just going to draw it back and pull in the nice tear-away sheath. Then through this, you'll drop a TDC, be it whatever brand you want.
It'll be a nice way to develop the track to eventually then convert to a HeRO. You could also use it for if someone needs to get central venous access for a poor or other things, you don't necessarily have to pull in the 16 French or 15 French or however big it is.
[Dr. Christopher Beck]
Right. You pull in whatever you need.
[Dr. Jason Wagner]
Yes. It's a nice way to get central venous access, again, from above.
[Dr. Christopher Beck]
Say you have an SVC occlusion, and so you're able to get just in the very lowest portion of the SVC, you can't just go-- I imagine if it's angled, you want to angle anteriorly. First, you have to go cephalad, and then angle anteriorly. How does that work? First, you just go the SVC portion, and then you turn the angle guide on and you can push anterior and up.
[Dr. Jason Wagner]
Correct. You want to be able to get it up to where the angle guides going to be up above or at the level of the clavicle because the needle guide will come up a little bit. One of the big things for this, and I know it's part of the IFU for sure, is that you need to have preoperative imaging. You can't just say, "Oh, this person's got a jugular occlusion. Sure. I wish to pull out a HeRO and a photosurfacer and just shove it in there and we'll do this thing."
You're going to want to have either venography and non-contrast CT or ideally a CT venogram or a CT with venous phase contrast so you can delineate the anatomy. Odds are the patients probably had it recently. If not, just get it because you want to make sure that if, a lot of these folks, one of the major contraindications to using a surfacer is if they have a nominal vein stent coming across from the left to the right, you're going to get tangled up in that and that's going to be a bad time. That's a direct against the IFU approach.
For me, I have been moderately aggressive in my use of it, but I think for me, the best part about it is if someone's got an occluded IJ from having prior catheters and you know where it's going to be occluded, there's going to be a little stump just off the SVC that you're going to be able to get your Surfacer into. Then from there, guide comes out, needle goes up, you're through the skin, and now you're back into the SVC from above.
[Dr. Christopher Beck]
Then, yes, you have access and you have–
[Dr. Jason Wagner]
Yes. I don't want to call it the chip shot Surfacer use, but it's a lot easier and a lot safer to start with those cases before you're doing the super aggressive, half the SVC is out and you're just wedging up into some collateral branch to then get your needle guide out. I have not been that aggressive yet. I also have just been fortunate that the patients that I've had have been relatively, I don't want to say chip shot, but more straightforward and approachable anatomy.
[Dr. Christopher Beck]
This was the reason I thought these two devices would marry well to each other. I guess I just thought there was room for patients who were maybe central venous occlusion, exhausted, access options in the arm, and then you use the Surfacer, recan the IJ or the SVC, and then boom. It's game on, you have access and then you could pull whatever you want. You mentioned a TDC, but you could also pull a HeRO grafted, right?
[Dr. Jason Wagner]
Yes. You can pull the HeRO in. They recommend that you do a TDC as a placeholder just to let the tissues maturing, so the tissues can just-
[Dr. Christopher Beck]
Acclimate.
[Dr. Jason Wagner]
-stabilize a bit around the catheter tract because it's not a true-- as of now, they don't have a way to easily pull in the HeRO stepwise dilator because you're not really going into a normally easily compressible from the outside place. It's better to have that pseudo-scarred into place tract first to then dilate that up, versus, if God forbid, you have a problem getting your dilator or something, you're not dealing with functionally a 20 French hole coming off the proximal SVC.
[Dr. Christopher Beck]
I see. I want to know, so if you have someone vacationing in Florida for the month and they end up seeing you for whatever reason and they're getting dialysis through a tunneled femoral catheter, is this a good patient if they have--? Will you work that patient up for potentially like, why do they have the groin catheter? Have you seen some situations where that led you to then use a Surfacer to then bring something up and get the tunnel catheter out of the leg and then put it in your standard IJ really?
[Dr. Jason Wagner]
Yes. I had one, we've had access to it in our hospital for about the past eight months. It's just right towards the tail end of our seasonal. You get the purchasing agreements and all this stuff approved through the hospital to actually get it on the shelf. As a shout out to Sarasota Memorial Hospital, they did a great job getting it approved quickly.
[Dr. Christopher Beck]
That's nice. We don't always get shoutouts to the hospital. That's a nice move.
[Dr. Jason Wagner]
They were great. It was towards the tail end of the snowboard season that we had access to it. I do have a standing, the wanted poster at a lot of the dialysis units and definitely the one in the hospital that if someone coming with a femoral line, call this number, call my office because we want to know that that's somebody that, at a minimum, we can get it above the waist. If they're going to be here for a month or two, then you can easily get the imaging and hopefully get them converted to a HeRO.
Some of the patients might just have a femoral line. Also, I'll map their upper extremities because some of them just have a femoral line because for some reason they might've had an occluded IJ on one side, nobody tried or whatever. They always throw an ephemeral line to be done. That's somebody that might just, if they've got an open IJ, don't worry, I love the Surfacer, but I'm not going to.
[Dr. Christopher Beck]
Yes, of course. [laughs]
[Dr. Jason Wagner]
That person can get a regular TDC on the right side, or even the left. Then we'll be able to go from there to get them an upper extremity access again, usually.
(9) The HeRO Graft & Surfacer Catheter System Learning Curve
[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 d
unk 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 correct
ly 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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