Kim Young, Cui Christina L, Eze Anthony Nnaemeka, Chun Tristen T, Kim Charles Y, Dillavou Ellen D, Cox Mitchell W, Southerland Kevin W
Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, NC.
J Vasc Surg. 2025 Oct;82(4):1458-1466.e1. doi: 10.1016/j.jvs.2025.05.042. Epub 2025 May 28.
The Hemodialysis Reliable Outflow (HeRO) graft offers hemodialysis access options for patients who have developed central venous stenosis or occlusion. In this single-center study, we report our perioperative and long-term outcomes after HeRO graft placement, and investigate the impact of conduit type and configuration on patency rates.
We retrospectively reviewed all HeRO graft procedures performed from January 2014 to December 2023 across three hospitals. Data were collected on patient demographics, operative details, postoperative outcomes, and patency. Only index HeRO graft procedures were included, and any subsequent or reoperative HeRO operations were excluded from analysis. Cox proportional hazards model was used to derive risk factors for loss of graft patency.
A total of 232 index HeRO implantations were performed over the 10-year study period. These included 49 primary procedures (23.1%) and 183 staged procedures (78.9%). Postoperative complications included wound infection (n = 18; 7.8%), symptomatic hematoma (n = 23; 9.9%), steal syndrome (n = 23; 9.9%), myocardial infarction (n = 3; 1.3%), and pulmonary embolism (n = 7; 3.0%). Overall primary patency was 33.0% ± 3.4% at 1 year, 6.4% ± 2.1% at 3 years, and 4.3% ± 1.9% at 5 years post-implantation. Secondary patency was 69.4% ± 3.4% at 1 year, 41.9% ± 4.4% at 3 years, and 28.0% ± 4.9% at 5 years post-implantation. Primary and secondary patency rates did not differ between primary and staged procedures (log-rank P = .46 and .73, respectively). On multivariate analysis, the use of a tapered 4- to 6-mm (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.11-7.49; P = .029) or tapered 4- to 7-mm conduit (HR, 1.82; 95% CI, 1.15-2.87; P = .011) was independently associated with loss of primary patency, compared with a non-tapered 6-mm graft. Tapered conduits were also associated with loss of secondary patency (4- to 6-mm tapered: HR, 3.68; 95% CI, 1.07-12.63; P = .039; 4- to 7-mm tapered: HR, 1.85; 95% CI, 1.01-3.37; P = .044). Neither graft type (standard vs early cannulation) nor procedure (primary vs staged) were associated with loss of primary or secondary patency.
Among patients with limited hemodialysis access options, HeRO graft implantation is associated with limited primary patency but acceptable secondary graft patency rates. In our experience, staged procedures and early cannulation grafts did not impact patency rates; however, the use of a tapered conduit was associated with loss of patency and should be considered with caution in this patient population.
血液透析可靠流出道（HeRO）移植物为已发生中心静脉狭窄或闭塞的患者提供了血液透析通路选择。在这项单中心研究中，我们报告了HeRO移植物置入后的围手术期和长期结果，并研究了导管类型和配置对通畅率的影响。
我们回顾性分析了2014年1月至2023年12月在三家医院进行的所有HeRO移植物手术。收集了患者人口统计学、手术细节、术后结果和通畅情况的数据。仅纳入首次HeRO移植物手术，任何后续或再次手术的HeRO手术均排除在分析之外。使用Cox比例风险模型得出移植物通畅丧失的风险因素。
在10年的研究期间共进行了232例首次HeRO植入手术。其中包括49例一期手术（23.1%）和183例分期手术（78.9%）。术后并发症包括伤口感染（n = 18；7.8%）、症状性血肿（n = 23；9.9%）、窃血综合征（n = 23；9.9%）、心肌梗死（n = 3；1.3%）和肺栓塞（n = 7；3.0%）。植入后1年总体原发性通畅率为33.0%±3.4%，3年时为6.4%±2.1%，5年时为4.3%±1.9%。继发性通畅率在植入后1年为69.4%±3.4%，3年时为41.9%±4.4%，5年时为28.0%±4.9%。一期手术和分期手术之间的原发性和继发性通畅率无差异（对数秩检验P分别为0.46和0.73）。多因素分析显示，与非锥形6mm移植物相比，使用4至6mm锥形（风险比[HR]，2.89；95%置信区间[CI]，1.11 - 7.49；P = 0.029）或4至7mm锥形导管（HR，1.82；95% CI，1.15 - 2.87；P = 0.011）与原发性通畅丧失独立相关。锥形导管也与继发性通畅丧失相关（4至6mm锥形：HR，3.68；95% CI，1.07 - 12.63；P = 0.039；4至7mm锥形：HR，1.85；95% CI，1.01 - 3.37；P = 0.044）。移植物类型（标准型与早期插管型）和手术方式（一期与分期）均与原发性或继发性通畅丧失无关。
在血液透析通路选择有限的患者中，HeRO移植物植入的原发性通畅率有限，但继发性移植物通畅率可接受。根据我们的经验，分期手术和早期插管移植物对通畅率没有影响；然而，使用锥形导管与通畅丧失相关，在该患者群体中应谨慎考虑。
