Contemporary Comparison between the Hemodialysis Reliable Outflow Device and Femoral Arteriovenous Graft.

KEY POINTS: Previously, femoral arteriovenous grafts were the standard approach for patients with upper extremity central venous occlusion. In our study, hemodialysis reliable outflow offered a higher likelihood of obtaining functional patency and fewer complications compared with femoral arteriovenous graft. These findings highlight that hemodialysis reliable outflow graft is a viable option for patients who have exhausted upper extremity arteriovenous access.

BACKGROUND

Hemodialysis reliable outflow (HeRO) graft and femoral arteriovenous graft (fAVG) are alternative options for patients who have exhausted upper extremity arteriovenous access because of central venous occlusion. This study aims to provide a contemporary comparison between HeRO and fAVG.

METHODS

Retrospective chart review of consecutive fAVG and HeRO placed between 2016 and 2023 at a multihospital health care system was conducted. Patients were identified using the local Vascular Quality Initiative database and supplemented by charts review. Baseline characteristics, operative details, and follow-up data were obtained. Data were analyzed using standard statistical tests, Kaplan-Meier survival analysis, and multivariate Cox proportional hazards.

RESULTS

Data for 114 access were collected (68 HeRO, 46 fAVG) from 105 unique patients. Patients receiving HeRO graftswere older (66.1 versus 57.7 years), had higher body mass index (31.8 versus 27.9 kg/m 2 ), and were more likely to have a history of atrial fibrillation (56% versus 20%) and fewer previous arteriovenous accesses (mean 1.4 versus 2.4). The ability to use the graft for hemodialysis was higher in the HeRO group (94% versus 83%; P = 0.049). At 36 months, the primary patency rate was 5% for the HeRO graft and 17% for the fAVG ( P = 0.45), while the secondary patency rates were 30% and 54% ( P = 0.25), respectively. Thrombosis was the predominant cause of HeRO graft abandonment (78%), whereas infection was most common for fAVGs (44%). On Kaplan‑Meier analysis, mortality was similar for HeRO graft and fAVG ( P = 0.22). Six (9%) patients from the HeRO group and ten (22%) from the fAVG group underwent graft removal because of infection ( P = 0.05). The rate of steal did not differ between both groups (HeRO 6% versus fAVG 11%; P = 0.33); however, among patients receiving fAVG, two required access ligation and two underwent limb amputation (HeRO, 0% versus fAVG, 9%; P = 0.01).

CONCLUSIONS

HeRO graft is a reasonable alternative for patients who have exhausted upper extremity arteriovenous access, offering a higher likelihood of obtaining functional patency and fewer complications compared with fAVG.