Lower Extremity Access versus HeRO Graft: Choosing Dialysis Access in Patients with Central Venous Stenosis

In patients with central venous stenosis, it is controversial whether an upper extremity Hemodialysis Reliable Outflow (HeRO) graft or lower extremity access is preferable. Furthermore, lower extremity grafts are contraindicated in patients with significant peripheral artery disease. The purpose of this study was to compare outcomes of HeRO grafts with lower extremity dialysis access in patients with central venous stenosis.

We performed a retrospective analysis of patients with central venous stenosis undergoing lower extremity dialysis access or HeRO graft placement at a large safety-net hospital from 2015 to 2022. Primary outcomes were 1-year primary patency, secondary patency, and mortality. Secondary outcomes were 30-day postoperative outcomes.

There were 25 patients included in this study. There was a higher rate of peripheral arterial disease in the patients undergoing HeRO graft placement, although not significant (33% vs. 6%, P = 0.12). One year mortality was significantly higher for patients who underwent HeRO graft (55% vs. 6%, P = 0.006). 1-year primary patency was higher for lower extremity access, although not significant (44% vs. 25%, P = 0.21). There was no difference in secondary patency at 1 year between HeRO grafts and lower extremity access (56% vs. 44%, P = 0.57).

Although our results are limited by small sample size, upper extremity HeRO grafts appear to have similar outcomes compared to lower extremity AV access in terms of primary and secondary patency. Thus, HeRO grafts are an acceptable alternative to lower extremity access in patients with central venous stenosis, particularly in patients who have peripheral artery disease who may not be candidates for lower extremity access.