The American Society of Diagnostic and Interventional Nephrology (ASDIN)’s 2023 meeting (17–19 February, Orlando, USA) has seen its second day start with style, as Tze-Woei Tan (Keck School of Medicine of the University of Southern California, Los Angeles, USA) opened a session on controversies in access care with a comparison of the upper extremity Haemodialysis Reliable Outflow (HeRO) graft and lower extremity grafts.
A self-professed early adopter of the HeRO graft, Tan began by noting that the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines advise that, once a patient with more than one year life expectancy has exhausted other upper extremity graft options, their clinician should next consider either a HeRO graft, a chest wall graft or a lower extremity graft. “However,” argued Tan, “it doesn’t really tell us which of these steps to take.”
Looking at each option in turn, he turned first to lower extremity grafts. These, he said, are “pretty rare,” noting that they only comprised 1–5% of access procedures. He cited a Journal of Vascular Surgery (JVS) study comparing HeRO with lower-extremity grafts led by Samuel Steerman (Sentara Vascular Specialists, Norfolk, USA), which found better primary patency for lower extremity, though similar secondary patency for both. That means that though HeRO graft patients need more reintervention, their access can be kept open, Tan said. Infections were comparable.
Another study from 2016 in the Journal of Vascular Surgery (JVS), however, found that the risk of thrombosis was “significantly lower in HeRO grafts”. A meta-analysis in the Journal of Vascular Access in 2018, meanwhile, found lower primary and secondary patency for HeRO but a lower rate of infection compared to lower extremity.
Summarising the findings, Tan called HeRO grafts a “reasonable” option for “patients without the option of upper extremity arteriovenous (AV) access due to central stenosis or occlusion”. While lower extremity grafts have consistently displayed “slightly superior patency”, he said, with HeRO requiring more reintervention, lower extremity grafts have similarly shown a higher infection and thrombosis risk.
“In my practice,” Tan concludes, “I decide whether to place thigh or HeRO grafts based on the patient’s anatomy. If they are younger, with longer life expectancy, I usually offer a fistula if possible—or, sometimes, a thigh graft. If they have a high risk of infection, I go for HeRO—just remember that they may need more reintervention.”