Contemporary Comparison Between the Hemodialysis Reliable Outflow (HeRO) Device and Femoral Arteriovenous Graft

Background: Hemodialysis Reliable Outflow (HeRO) graft and femoral arteriovenous graft (fAVG) are alternative options for patients who have exhausted upper extremity AV access due to 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. Cases 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 analysed 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. HeRO patients were older (66.1 vs 57.7 years), had higher body mass index (31.8 vs 27.9 kg/m2), were more likely to have a history of atrial fibrillation (56% vs 20%), and fewer previous AV accesses (mean 1.4 vs 2.4). The ability to use the graft for hemodialysis was higher in the HeRO group (94% vs 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 and fAVG (p=0.22). Six (9%) patients from the HeRO group and 10 (22%) from the fAVG underwent graft removal due to infection (p=0.05). The rate steal did not differ between both groups (HeRO 6% vs fAVG 11%; p=0.33); however, among fAVG patients, two required access ligation and two underwent limb amputation (HeRO: 0% vs fAVG: 9%; p = 0.01). Conclusions: HeRO is a reasonable alternative for patients who have exhausted upper extremity AV access, offering higher likelihood of obtaining functional patency and fewer complications compared to fAVG.