Hemodialysis Reliable Outflow (HeRO) Catheter Outcomes in Patients with Long-Standing Renal Failure: Optimizing Performance

OBJECTIVES:
Due to the increasing population of access-challenged dialysis patients, the HeRO device is becoming a more recognized alternative option for patients who are tunneled dialysis catheter (TDC) dependent. We have developed criteria and risk factors that we hope will improve patency, reduce infection, and ultimately improve the performance of the HeRO device in this high risk population.
METHODS:
A single-institution retrospective review of all HeRO implants from May 2008 through June 2009 was performed. Patient demographics, patient history, and implant success were evaluated. Cephalosporin was the preferred prophylactic antibiotic. Primary outcomes were successful implantation, patency rates, and infection. Secondary outcomes were morbidity and mortality.
RESULTS:
Forty-two procedures were performed, yielding 40 successful implants (95%). Mean age was 57.5 years. The majority (95%) were African American with at least 2 major comorbidities. Almost all patients (n=39) were TDC dependent. Mean duration on hemodialysis (HD) was 7.6 years. Mean number of HD catheters, arteriovenous grafts, and arteriovenous fistulae per patient prior to implant were 7.2, 1.4, and 1.9 respectively. The overall infection rate was 20% (n=8) with a device-adjusted infection rate of 1.09/1000 device days. Seven of these were in patients with insulin-dependent diabetes (IDDM) (17.5% vs. 2.5%, p=0.007). One month patency was 90% with 53% (n=21) currently using the HeRO for dialysis after a mean follow-up of 4.1 months. Patients taking plavix were less likely to develop device thrombosis (0% vs. 32.5%, p=0.025). The number of prior access procedures (> 5) was associated with device thrombosis (2.5% vs. 45%, p=0.005) and device-related infections (0% vs. 20%, p=0.021). Thirty day mortality was 13% (n=5) which were not related to the procedure. Overall 1-year survival was 72.5%.
CONCLUSIONS:
In this high risk patient population, the HeRO device can be placed successfully with low morbidity. Factors which may optimize performance include the postoperative use of plavix, use of the device earlier in traditional dialysis access algorithms, and possibly the administration of broad spectrum antibiotics perioperatively.