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Aisha Shaikh
@aishaikh
, 21 tweets, 10 min read Read on Twitter
💥HeRO Graft Tweetorial

⚡️’HeRO’ stands for ‘Hemodialysis
Reliable Outflow’
⚡️What Nephrologists need to know
about HeRO👇🏽
⚡️HeRO graft: Indications, Outcomes
& Complications
1/
 @ASDINNews
@SocietyAccess
@RenalFellowNtwk
#HeRO
💥What is a HeRO Graft?

⚡️It is half graft + half catheter
⚡️Fully Subcutaneous

⚡️Graft-component is connected to the artery at one end & to the catheter at the other end

⚡️Catheter-component serves as venous outflow w/ it’s tip @ SVC/R. atrium
2/
💥Is any part of the HeRO graft exposed externally?
⚡️No

⚡️Graft-part is subcutaneous just like the conventional AVG

⚡️Catheter-part traverses the central veins BUT instead of sticking out through the skin it connects subcutaneously w/ the graft👇🏽
3/
💥What is the difference b/w the HeRO graft & the tunneled dialysis CVC?

⚡️Unlike CVC, no part of the HeRO graft is exposed to the outside as it is fully subcutaneous 👇🏽

⚡️Hence the rate of infection is ⬇️ w/ HeRO vs. CVC
4/
💥What is the difference b/w the HeRO graft & conventional AVG?

⚡️In a conventional AVG, one end is connected to the artery (inflow) & the other to the vein (outflow) hence there is a ‘venous anastomosis’

⚡️In HeRO, there is NO ‘venous anastomosis’👇🏽
5/
💥Indications for HeRO graft placement?

⚡️In pts. who cannot get a conventional AVG or AVF due to central vein stenosis

⚡️Key to successful HeRO placement - one should be able to pass the catheter-component of the HeRO thru the stenosed central vein👇🏽
6/
💥HeRO graft cannulation technique is similar to the conventional AVG cannulation

⚡️You can only canulate the ‘graft-component’ of the HeRO & NOT the ‘catheter-component’ 👇🏽
7/
💥How does HeRO graft compare to conventional AVG in terms of patency?

⚡️To date there has been 1 RCT comparing the two & it showed similar patency b/w the two groups, but the Trial was under-powered 👇🏽
8/
💥Overall primary & secondary patency of the HeRO graft was later described in this publication👇🏽

⚡️Review of 8-studies: 409 pts. w/ HeRO showed:
☄️1-yr Primary patency: ~22%
☄️1-yr Secondary patency: ~ 59%
👇🏽
9/
💥Rate of interventions required to maintain HeRO graft patency?
⚡️~1.5 to 3 interventions/yr

💥Rate of interventions required to maintain patency of CVC & conventional AVG?
⚡️CVC: ~ 5.8/yr
⚡️Conventional AVG: ~1.6 to 2.4/yr
👇🏽
10/
💥How does HeRO graft compare to CVC regarding incidence of bacteremia?

⚡️Rate of bacteremia with HeRO is
~0.13-0.7 episodes per 1000-days, which is ⬇️ compared to the rate of bacteremia reported with CVCs ~0.6-6.5 episodes per 1000-days
11/
💥Are HeRO grafts more cost-effective than tunneled CVCs?
⚡️Yes

⚡️Even though the initial cost of HeRO placement is ⬆️ than the CVC, the overall cost of HeRO is ⬇️ due to the lower occurrence of thrombosis & infection with HeRO vs. CVC
12/
💥How does HeRO graft compare to conventional AVG regarding incidence of bacteremia?
⚡️No difference

⚡️But this Trial was underpowered 👇🏽
13/
💥HeRO graft allows pts. to have an upper ext. AV access even if they have central vein stenosis

⚡️In other words, w/ a HeRO a pt. can not only avoid a CVC but can also avoid a lower extremity AV access

⚡️But how does HeRO compare to LE
AVG & LE AVF?
14/
💥HeRO graft vs. Femoral AVG

⚡️No prospective studies

⚡️Retrospective, Single center studies show:
☄️No diff. in infection rate
☄️Some studies show ⬇️ patency w/
HeRO
☄️Some studies show ⬆️ # of
interventions needed for HeRO
15/
💥HeRO graft vs. Femoral AVF

⚡️Retrospective, Single center study:
☄️⬇️ HeRO patency
☄️⬆️ # of interventions needed
for HeRO

⚡️Limitation: Many centers do not
have the surgical expertise to
create fAVF
16/
💥Is it possible to place a HeRO Graft in the lower extremity?
⚡️Yes

⚡️Even though HeRO grafts are predominantly placed in the upper extremity, there are case reports of HeRO graft placement in the lower extremity👇🏽
17/
💥Complications of HeRO graft

⚡️HeRO is half graft + half catheter:
therefore the complications
associated with it are those seen
with both AVGs and CVCs
⚡️Summarized 👇🏽
18/
💥One complication associated w/ HeRO graft is Pulmonary Embolism

⚡️Source of PE is likely R atrial thrombi that form due to the CVC-portion of HeRO irritating the atrial wall👇🏽

⚡️Consider removal of HeRO if dialysis is stopped (eg. post-transplant)
19/
💥 A Clinical Case highlighting the utility of HeRO Graft in a patient with central vein stenosis👇🏽
20/
💥Summary:

⚡️HeRO graft is Catheter-sparing

⚡️HeRO graft has ⬆️ patency & ⬇️
rate of bacteremia vs. CVCs

⚡️HeRO graft allows patients to avoid
a lower extremity dialysis AV
access in the setting of central vein
stenosis

21/
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Aisha Shaikh
@aishaikh
💥’Physical Examination of the Dialysis Vascular Access’ - Tweetorial

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@aishaikh
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Aisha Shaikh
@aishaikh
The #CREDENCE Trial was discussed @NephJC last night. We were fortunate to have the lead author of the paper @VladoPerkovic join in. He took questions from the participants. Here is the summary of his responses 👇🏽
#CREDENCE
#NephJC
@hswapnil
@kidney_boy
Q1: Why was the 100 mg dose of Canagliflozin used in #CREDENCE and not the 300 mg dose?
VP: We were anxious about the toxicity as seen in some previous trials, & we wanted to minimize that risk
#NephJC
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VP: That was a regulatory request from Germany 🇩🇪
#NephJC
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