HeRO's Don't Always Win: Evaluating HeRO Grafts in Contemporary Dialysis Access

The introduction of the hemodialysis reliable outflow (HeRO) graft in 2009 presented an alternative upper extremity access for hemodialysis (HD) patients with failing access sites. Despite initial enthusiasm, experience has revealed strengths and limitations of HeRO access. This study's objective is to assess the contemporary use of HeRO grafts at 2 tertiary care centers.

The operative logs for patients undergoing HD access procedures were retrospectively reviewed at 2 tertiary care sites between January 2012 and July 2024. Only patients that underwent placement of a HeRO graft were abstracted for analysis. The average patient age, HeRO graft indication, HeRO graft technical construct, use of post-HeRO systemic anticoagulation, and HD interventions pre-/post-HeRO access procedure were abstracted. All other patients who did not undergo a HeRO graft intervention were excluded.

Eighteen patients with end-stage kidney disease were identified as having undergone placement of a HeRO graft. Prior to HeRO placement, patients underwent 4.61 ± 3.91 HD access maintenance procedures. The most common construct for HeRO graft inflow was brachial artery to polytetrafluoroethylene (PTFE), 55%, followed by arteriovenous outflow vein to PTFE, 33%, and PTFE graft to graft, 11%. After HeRO placement, patients underwent 1.94 ± 1.77 HD access maintenance procedures. The primary patency rates at 6 months and 1 year were 50% and 47%, while secondary patency at 1 and 5 years were 80% and 27%, respectively. The most common post-HERO complication was graft thrombosis. Ultimately, 72% of patients required systemic anticoagulation to maintain HeRO graft patency.

This contemporary analysis of HeRO graft use indicates the value of HeRO access: a lower number of reinterventions to maintain graft function, and relatively low incidence of access complications. Anticoagulation was required in the majority of HeRO patients. There was a statistically significant reduction in the number of HD access interventions after HeRO placement.