IP159. Use of Hemodialysis Reliable Outflow (hero) with Immediate Access Arteriovenous Grafts

In patients with central venous occlusive disease, combining immediate-access arteriovenous grafts with outflow through the Hemodialysis Reliable Outflow (HeRO) graft presents a novel strategy to reduce or avoid catheter use for dialysis. The Acuseal graft (W. L. Gore & Associates, Flagstaff, Ariz) has been approved for cannulation within 24 hours of placement. The real-world performance of this treatment modality has not been reported. All patients who underwent placement of Acuseal graft from January 2014 through April 2016 at two large tertiary referral centers were retrospectively identified in the electronic medical record. Of these, patients who received this as part of a HeRO or in anastomosis to an existing HeRO graft were included. When placed primarily, the Acuseal was anastomosed to the standard graft that was included in the HeRO kit ∼3 cm from the connector to the silicone outflow. Demographic data, primary, primary assisted, and secondary patency rates, time to cannulation, and infection were recorded. Patency was defined per Society for Vascular Surgery recommended reporting standards and was determined from the time of the index procedure. Outcomes were compared using Pearson χ2 tests for categoric variables and Wilcoxon rank sum tests for continuous variables. Forty-four patients (mean age, 58.4 ± 14.6 years; 50% male) underwent placement of a combined Acuseal-HeRO graft. Mean follow-up time was 7.6 ± 8.6 months. Overall primary, primary assisted, and secondary patencies at 6 months were 35.9%, 43.6%, and 51.3%, respectively, and 95% of grafts were successfully cannulated, with mean time to cannulation of 13.0 ± 51.6 days. One graft was excised prior to cannulation due to infection. A total of 84% were cannulated within 14 days of placement. In this group, average first cannulation was at 1.7 ± 1.7 days. In the delayed cannulation group (>14 days), there was a significantly higher rate of graft infection compared to the early cannulation group (42.8 vs 8.1%; P = .014). No access-related hematomas were observed. Patients were discharged on aspirin (13.6%), aspirin and clopidogrel (29.5%) or warfarin (20.5%), without patency differences. Seven patients underwent revision of an existing HeRO graft with Acuseal with mean follow-up time of 9.7 ± 11.9 months. For revisions, primary, primary assisted, and secondary patencies at 6 months were 40%, 40%, and 60%, respectively. One graft infection was observed in this group. Acuseal-HeRO allows for immediate access in patients with limited options, with reasonable rates of complications and patency. Delayed graft cannulation is associated with higher rate of infection, likely related to prolonged catheter dwell time.