The HeRO Graft. Shawn M. Gage, PA Division of Vascular Surgery Duke University Medical Center
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1 The HeRO Graft Shawn M. Gage, PA Division of Vascular Surgery Duke University Medical Center
2 Faculty Disclosure I disclose the following financial relationships: CryoLife/Hemosphere, Inc. & W.L. Gore and Associates. - paid consultant, speaker, instructor Je déclare les informations suivantes: CryoLife/Hemosphere, Inc. & W.L. Gore and Associates. - payé consultant, conférencier, formateur
3 Outline Central vein occlusion challenges Current options Indications Planning Implant procedure Data
4 The Problem: Central venous occlusion Recurrent central venous instrumentation Central venous catheters Balloon Angioplasty Central venous stents Shear stresses HD associated Inflammation Aggressive venous intimal hyperplasia
5 LE access - infection/steal Central vein reconstruction - morbid / complications Destination Dialysis Catheter - infection / poor dialysis adequacy Current Options
6 A Brief Overview HeRO Hemodialysis Reliable Outflow Hybrid vascular access device graft-cath 2 primary components: eptfe graft with Titanium connector, and radiopaque silicone outflow component (OC) Common access veins include: Subclavian and Internal Jugular End stage access device Indicated for catheter dependent patients with central venous stenosis and/or occlusion eptfe Graft Component Venous Outflow Component
7 Indications CV stenosis CV occlusion TDC dependence Maintain upper body access Access salvage
8 Why is this device important? Infection Reduction * Reduced Intervention * Reduced Healthcare spending * Improved dialysis adequacy * Access salvage Access Longevity * over TDCs
9 Planning History - previous catheters - # previous access Physical exam - inflow - chest wall collaterals - neck, extremity, or facial edema - old access scars and location
10 Planning / Imaging MRV (Feraheme) Conventional venography
11 Equipment Venous Outflow Component Arterial Graft Component Accessory Component Kit
12 HeRO Implant Accessories Included in the Accessory Kit: 12F & 16F sequential dilators 20F Peel-away sheath with dilator long and short option 10F Delivery Stylet Y-port with stopcock valve Clamp Hemostasis plug
13 Venous Outflow Component Silicone inside & out Kink and crush resistant nitinol reinforced braid Radiopaque marker 5mm ID 6.3mm (19F) OD 40cm long
14 Arterial Graft Component Standard eptfe graft Titanium connector Beading near connector 6mm ID 7.4mm OD 53cm long
15 Implant Procedure
16 Obtain Central Venous Access Catheter cut down or percutaneous Angiogram Angioplasty
17 Insert Outflow component (OC)
18 Connect Outflow component to PTFE eptfe graft Silicone outflow component
19 Complete arterial anastomosis
20 Recent Data
21 Patency
22 Patency Comparison of Published HeRO data, AVG Literature, and TDC Literature
23 Bacteremia and Intervention Comparison of Published HeRO Data, AVG Literature, and TDC Literature
24 Conclusions HeRO graft allows establishment of access in setting of central venous occlusive disease Maintain upper body access Reduced morbidity and mortality Reduced cost to healthcare system Patency & intervention rates are comparable to standard AVGs Infection and intervention rates superior to TDCs Access salvage and longevity
25 Merci Shawn M. Gage, PA-C Division of Vascular Surgery Duke University Medical Center
26 Pitfalls OC positioned too high Coupler too lateral OC and graft NOT tunneled to same plane Crushed Beading Inadequate inflow Communicate with Anesthesia when opening HeRO
27 Myths More likely to cause steal Cannot be used in patients with poor EF Titanium coupler causes thrombosis 1 Poiseuille's Law (pwas-weez) 1 Grezaffi JA, Bryant J, Lessne ML, Kim C: Early experience with percutaneous interventions for failing HeRO arteriovenous grafts. Presented at the Society for Interventional Radiology, Chicago, IL, March 2011
28 Tips and Tricks Use stiff wire Angioplasty outside of the body Use 6mm balloon if delivery stylet does not work Completely remove peel-away sheath Graft-OC connection
29 Declot Procedure Similar to standard AVG Similar time requirement Percutaneous or open Fogarty balloon or Angiojet Clot non-adherent to OC No venous anastomosis to manage
30 Modified Implant Techniques Chest wall HeRO Contralateral extremity inflow
31 Patient New to Hemodialysis History, Physical Exam, and Duplex Ultrasound A A Non-Dominant Arm (NDA) Wrist AVF NDA Elbow AVF L G C NDA Brachiobasilic AVF -OR- Dominant arm (DA) wrist AVF Yes Young patient -ORnot on HD No NDA Forearm Loop AVG O C E DA Elbow AVF NDA Forearm Loop AVG NDA Upper Arm AVG NDA Upper Arm AVG NDA AX-AX teardrop -OR- chest wall AVG DA Wrist or elbow AVF R I S NDA AX-AX teardrop -OR- chest wall AVG DA Forearm Loop AVG T S DA Upper Arm AVG DA AX-AX teardrop -OR- chest wall AVG Upper Extremity HeRO TM Femoral AVG H M Figure 3: Algorithm demonstrating order of basic access site selection from new renal failure patient to end stage access patient.
32 HeRO implant specifics
33 Logistics, Room & Bed Positioning Which extremity C-Arm location Monitor locations Instrument table Wire tables Monitor
34 Recanalization Procedure Upper and lower extremity venous access Multi-projection imaging Low profile catheters Sharp recanalization Through-and-through guidewire access Balloon angioplasty Access place-holder
35 Right BCV & SVC Occlusion Collateral veins Occluded Left BCV stent
36 Axillary and Femoral vein access Low profile directional catheters Long rigid sheath TIPS needle
37 Crossed occlusion Through and through venous access body floss trackability
38 Balloon Angioplasty Dilate tract
39 Low profile catheter implanted as place-holder
40 Current Options Lower extremity AV access - increased risk of infection - greater risk for LE steal
41 Current Options Direct bypass to right atrium or CV reconstruction Requires sternotomy or thoracotomy High morbidity Sternal wounds Graft infections Pleural or pericardial effusions
42 Current Options Destination Dialysis Catheter - Increased infection risk - poorer dialysis adequacy - greater number of interventions - highest cost to healthcare system
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