PS178. Expanded Use of the Hemodialysis Reliable Outflow (HeRO) Vascular Access Device for Permanent Dialysis Access in Patients with Total Central Venous Occlusion

Central venous occlusion often results in reliance on catheter-based dialysis access, which is a well-established source of significant morbidity and mortality. We retrospectively reviewed our experience with recanalization of totally occluded central venous segments and subsequent implantation of the HeRO vascular access device to provide permanent access in this catheter-dependent population. From September 2008 to July 2010, eight catheter-dependent patients with total central venous occlusion were identified. A catheter and guidewire system, using both an upper extremity and femoral approach, was used to traverse the central occlusion. Angioplasty was performed to secure a tunneled catheter across the occluded segment for future guidewire access and HeRO implantation. A temporary tunneled catheter was used for hemodialysis access until the HeRO graft was suitable for cannulation. HeRO implantation was successfully performed in all eight patients. The mean age and length of time on dialysis was 53.6 and 6.9 years, respectively. The recanalized central venous segment was the superior vena cava (n=4), brachiocephalic vein (n=3), or subclavian vein (n=1). One patient died on postoperative day 11 of unrelated gastrointestinal bleeding. Mean follow-up for the remaining seven patients was 12.9 months (range 5-23 months). On average, grafts were successfully accessed in 22.6 days, with patients catheter-free at 29 days. Primary and secondary patency rates at 6 months were 51% and 100%, respectively. One graft required revision secondary to local infection. Recanalization of totally occluded central venous segments followed by implantation of the HeRO device for permanent dialysis access is feasible, with excellent short-term patency in our current series. This strategy may reduce the morbidity associated with chronic indwelling hemodialysis catheters, and extend anatomic options previously abandoned in high-risk patients.