HeRO. Jeffrey H. Lawson, M.D., Ph.D. Departments of Surgery and Pathology Duke University Medical Center Durham, North Carolina
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1 HeRO Jeffrey H. Lawson, M.D., Ph.D. Departments of Surgery and Pathology Duke University Medical Center Durham, North Carolina
2 Disclosures Consulting, Clinical Trials and Opinion Hemosphere Ark Therapeutics Baxter Research Lemaitre American Heart Johnson & Johnson/Ethicon ACS Endologix NIH Zymogenetics ADA Gore Medical HHMI Atrium Medical NovoNordisk Pervasis Therapeutics Nanovasc
3 Superheroes
4 Heroes
5 Hemodialysis with Reliable Outflow (HeRO) Outflow Component Titanium Connector Tip to Right Atrium Graft Component Dialysis Access
6 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
7 Current Options Lower extremity AV access - increased risk of infection - greater risk for LE steal
8 Current Options Direct bypass to right atrium or CV reconstruction Requires sternotomy or thoracotomy High morbidity Sternal wounds Graft infections Pleural or pericardial effusions
9 Current Options Destination Dialysis Catheter - Increased infection risk - poorer dialysis adequacy - greater number of interventions - highest cost to healthcare system
10 State-of-the Art??? C.W. 50 yo BF with No Access
11 State-of-the Art??? Death via Catheter Sepsis!! Transhepatic Permcath C.W. 50 yo BF with No Access
12 Proposed Solution Central Venous Recanalization With Hemodialysis Reliable Outflow as adjunct
13 Occluded SVC with Access to the RA via the L Subclavian Vein 66 year old woman with multiple extremity access grafts currently dialyzed through a left internal jugular TDC History of prior SVC occlusion managed with angioplasty and stenting
14 History Of Occluded SVC, but access to the SVC via the Subclavian
15 Implantation Specifics HeRO Implant Side HeRO Implant Side Right Left Right Left % (n/n) 58.5 (24/41) 39.0 (16/41) 2.4 (1/41)
16 Implantations Specifics Outflow Vein Outflow SVC Azygos IVC % (n/n) 90.2 (37/41) 7.3 (3/41) 2.4 (1/41)
17 Patency & Intervention Rates Patency Primary, % Secondary, % Duke 6 months Multi Center Trial 8.6 mo mean f/u a b 72.2 AVG literature 6 months TDC literature 6 months 50 5, , 6 Intervention Rates, per year , , 6 1. Katzman HE, et al. Initial Experience and Outcome of a New Hemodialysis Access Device for Catheter-Dependent Patients. J Vasc Surg 2009;50: Sidawy AN, et al. Recommended Standards for Reports Dealing with Arteiovenous Hemodialysis Access. J Vasc Surg 2002;35: Bosman PJ, et al. A Comparison Between PTFE and Denatured Homologuous Vein Grafts for Haemodialysis Access: A Prospective Randomized Multicenter Trial. Eur J Vasc Endovasc Surg 1998;16: Madden RL, et al. A Comparison of Cryopreserved Vein Allographs and Prostetic Grafts for Hemodialysis Access. Ann Vasc Surg 2005; 19: Rocklin MA, et al. Comparison of cuffed tunneled hemodialysis catheter survival. Am J Kidney Dis 2001;37: Duszak R, et al. Replacement of failing tunneled hemodialysiscatheters through pre-existing subcutaneous tunnels: a comparisonof catheter function and infection rates for de novo placements and over-the -wire exchanges. J Vasc Interv Radiol 1998;9: a. (n/n) 19/28 patients b. (n/n) 32/36 patients
18 Infection Rates HeRO Cohorts No. Total Days Bacteremia events Bacteremia rate/1000 days (TDC) Control rate/1000 days 1 Overall Duke 41 Multicenter , Bridging Period Duke 39 Multicenter Alone Duke 35 Multicenter Katzman HE, et al. Initial Experience and Outcome of a New Hemodialysis Access Device for Catheter-Dependent Patients. J Vasc Surg 2009;50:
19 The HeRO Body Floss
20 Right BCV & SVC Occlusion Collateral veins Occluded Left BCV stent
21 Axillary and Femoral vein access Low profile directional catheters Long rigid sheath TIPS needle
22 Crossed occlusion Through and through venous access body floss trackability
23 Balloon Angioplasty Dilate tract
24 Low profile catheter implanted as place-holder
25 Results CVR Specifics Successful CVR, % (n/n) 83.3 (15/18) Thru & Thru access, % (n/n) 67 (10/15) Catheter placed, % (n/n) 87 (13/15) CVR to HeRO (days), mean (range) 32.5 (0 148)
26 Results HeRO Implant Specifics Successful implants, % (n/n) 93.3% (14/15) Side of body, % (n/n) Right 64 (9/14) Insertion vein, % (n/n) Subclavian Internal Jug External Jug Other 36 (5/14) 29 (4/14) 14 (2/14) 21 (3/14)
27 Results Intervention - Overall 71% FFI Infection - 1 HeRO related infection - required interposition replacement of eptfe Death - 3 deaths (21%) - All unrelated to recanalization or HeRO implant
28 Conclusions Central venous recanalization is feasible HeRO device allows for durable access Maintain upper body access Patency & intervention is acceptable Reduced cost to healthcare system Reduced morbidity and mortality
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IL0118 Rev.0 1 COVERA Vascular Covered Stents Innovation in AV Access Dheeraj Rajan, MD, FRCPC, FSIR Head and Associate Professor, Division of Vascular & Interventional Radiology Department of Medical
Which Stent Is Best for Various Femoropopliteal Anatomy? 2018 Pacific Northwest Endovascular Conference June 15-26, 2018 Seattle, WA
Which Stent Is Best for Various Femoropopliteal Anatomy? 2018 Pacific Northwest Endovascular Conference June 15-26, 2018 Seattle, WA Brian DeRubertis, MD, FACS Associate Professor of Surgery UCLA Division
Angioplasty remains the most common method
When AVF Angioplasty Fails Defining procedural success and overcoming common problems. By Thomas M. Vesely, MD Angioplasty remains the most common method of treating obstructive vascular stenoses associated
Surgical Options in Thrombectomy for Non-Surgeons
Surgical Options in Thrombectomy for Non-Surgeons Shouwen Wang, MD, PhD, FASDIN AKDHC Ambulatory Surgery Center Arizona Kidney Disease and Hypertension Center Phoenix, Arizona Disclosure No relevant financial
2 Aortic Arch Debranching UCSF Vascular Symposium /14/16. J Endovasc Ther 2002;9:suppl 2; II98 105
How I Do It: Aortic Arch Debranching Exposures, Tunnels and Techniques Warren Gasper MD Assistant Professor of Surgery UCSF Vascular Surgery No disclosures 2 Aortic Arch Debranching UCSF Vascular Symposium