The success of hemodialysis depends on reliable vascular access, with arteriovenous fistulas (AVFs) being the preferred option, followed by arteriovenous grafts (AVGs). However, some patients exhaust these conventional options, necessitating alternative approaches such as the Hemodialysis Reliable Outflow (HeRO®) Graft. We report the case of an 84-year-old male with end-stage kidney disease, systemic arterial hypertension, type 2 diabetes mellitus, and a history of myocardial infarction who had no remaining sites for arteriovenous fistula or graft creation. A novel configuration of the HeRO® Graft was used, with the proximal anastomosis to the left axillary artery and the distal end implanted in the left femoral vein (axillo-femoral configuration). The device remained patent and functional for two years, providing adequate hemodialysis access. This approach highlights the feasibility of an unconventional HeRO® Graft configuration and expands the device's potential applications in managing complex clinical scenarios.

The success of hemodialysis for patients with end-stage kidney disease (ESKD) largely depends on the availability of functional vascular access. According to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, an arteriovenous fistula (AVF) is the gold standard for hemodialysis access due to its higher long-term patency and reduced complication rates compared to other access types [1-3]. When an AVFs is not viable, an arteriovenous graft (AVG) is typically used as the next alternative 1. However, many patients eventually exhaust these conventional options due to progressive vessel injury from repeated cannulation, the development of central venous stenosis or occlusion after multiple catheter placements, diffuse atherosclerosis, and the cumulative failure of previous accesses 4–6. In such complex scenarios, management becomes particularly challenging and alternative approaches must be considered. The Hemodialysis Reliable Outflow (HeRO®) Graft (Merit Medical, South Jordan, Utah) is a hybrid vascular access device indicated for patients with ESKD who have central venous stenosis or occlusion and are not candidates for AVF or AVG creation. Unlike standard arteriovenous access options, the device is designed to bypass central venous stenosis or occlusion. Candidates for the HeRO® graft should meet specific criteria that align with an individualized ESKD life plan. These include [1] exhaustion of all arteriovenous access options in the upper extremities; [2] adequate blood pressure to support the device's function; [3] appropriate anatomy, including a suitable inflow artery and either a patent or correctable central venous outflow; and [4] an anticipated long-term need for hemodialysis, typically exceeding one year [1]. This study introduces an innovative use of the HeRO® Graft in a patient with ESKD who had exhausted all conventional vascular access options. We describe the device use in an axillo-femoral configuration, an approach not previously documented in the literature, detailing the technical aspects and clinical outcomes of this novel application. This case report was prepared in accordance with the CARE Equator guidelines.

An 84-year-old male patient with multiple comorbidities, including systemic arterial hypertension, type 2 diabetes mellitus, CKD on hemodialysis, and a history of acute myocardial infarction, presented with significant bleeding from an AVF in the right upper limb, probably related to coumarin intoxication. Initially, the patient underwent endovascular correction of a pseudoaneurysm and a double-lumen central venous catheter placement to enable hemodialysis. However, due to complications such as flow difficulties, this was replaced by a double-lumen tunneled catheter (Permcath CentrosFLO®; Merit Medical, South Jordan, Utah) implanted in the femoral vein of the right thigh. An attempt to perform angioplasty to restore patency in the AVF of the right upper limb was unsuccessful due to venous stenosis and severe calcification of the previously used brachial artery, requiring the AVF to be surgically ligated. The patient had also previously undergone bilateral central venous angioplasty up to the junction of the right atrium and superior vena cava; however, the procedure was unsuccessful, and the vessels subsequently became occluded, precluding any conventional central venous approach. Considering the patient was no longer a candidate for new AVFs or conventional AVGs, an arteriovenous access was created using a HeRO® Graft. The device (Figure 1) features an arterial graft component made of expanded polytetrafluoroethylene (ePTFE) with PTFE beading, measuring 53 cm in length and transitioning via a titanium connector to the venous outflow component. The venous outflow component consists of a radiopaque silicone tube reinforced with braided nitinol. This segment includes a radiopaque marker band for precise placement and measures 40 cm in length. 

                                                                                                                            Figure 1 – HeRO® device.

                                                     Figure 2: Surgical steps for axillo-femoral arteriovenous graft placement using the HeRO® device.

Panel A: Exposure of the left axillary artery in the deltopectoral groove. Panel B: Anastomosis between the axillary artery and the PTFE segment of the HeRO® device. Panel C: Subcutaneous tunneling of the device through the left hemithorax (note the varices in the thoracic region). Panel D: Subcutaneous passage of the HeRO® graft and connection between the PTFE segment and the venous end of the catheter.

Figure 3: Schematic anatomical illustration of the HeRO® Graft in axillo-femoral configuration. The device is shown connecting the left axillary artery (inflow) to the left femoral vein (outflow) through a subcutaneous tunnel along the left lateral thorax.

Figure 2 shows the main intraoperative steps, while Figure 3 provides a schematic representation of the axillo-femoral configuration of the graft. The surgical procedure involved the anastomosis of the proximal end of the HeRO® Graft to the axillary artery in the left upper limb, using it as the arterial inflow source (Figure 2B). The axillary artery was approached through a skin incision in the anatomical depression between the deltoid and pectoralis major muscles, with exposure of the vessel achieved by opening the pectoralis minor (Figure 2A). The final graft length was determined along the planned subcutaneous course, measuring approximately 90 cm. The device was then tunneled through the subcutaneous tissue along the lateral mid-thoracic line, using staggered transverse incisions at approximately 15 cm intervals. This approach allowed direct visualization during advancement and confirmation of proper orientation, thereby preventing torsion and ensuring adequate tension (no specific maneuver or device was required to avoid kinking or compression). The distal end of the device was implanted into the left femoral vein in the inguinal region (Figure 2D). Postoperatively, antiplatelet therapy with acetylsalicylic acid 100 mg once daily was prescribed for three months. The axillary artery was selected as the arterial inflow source due to its typically lower degree of atherosclerosis and reduced calcification index, making it a more suitable option for anastomosis. The ipsilateral femoral artery (left) exhibited severe calcification and distal arterial occlusion, which would have increased the risk of arterial steal syndrome and further exacerbated limb ischemia if used for graft placement. The femoral vein was chosen for venous outflow to provide a longer, more accessible trajectory for vascular access puncture. 

One day after the procedure, the patient developed steal syndrome in the left upper limb. The condition was managed conservatively with close clinical observation and resolved spontaneously without surgical or pharmacological intervention. Three days after the procedure, a Doppler ultrasound revealed diffuse atheromatosis but no significant stenoses. During clinical evolution, the patient faced systemic complications, including septic shock, infectious endocarditis caused by Staphylococcus aureus, aspiration pneumonia, and pseudomembranous colitis, all managed with targeted interventions. Despite these complications, the graft's patency was confirmed by Doppler ultrasound two months after the procedure. The HeRO® Graft remained functional and successfully maintained hemodialysis access for two years. After this period, a Schiley catheter was implanted in the femoral vein of the right thigh as a temporary alternative. The catheter was placed to avoid graft use until the resolution of a puncture-related hematoma, most likely caused by inadequate cannulation. Approximately 21 days later, the HeRO® Graft was re-used without further complications.

Managing vascular access in patients with ESKD remains a challenge, particularly in individuals who have exhausted conventional options such as AVFs and AVGs. The decision to use the HeRO® Graft in this case was guided by its potential advantages over other available alternatives, such as repeated central venous balloon venoplasty or stenting. Although the HeRO® Graft is associated with lower one-year primary (21.9%) and secondary (59.4%) patency rates compared to native AVFs or AVGs [7], in our case, the device remained functional for two years, surpassing the average patency reported in the literature. This favorable outcome underscores the potential of the axillo-femoral configuration to provide durable access in complex patients with limited options. Alternative approaches, such as lower limb arteriovenous grafts, have shown similar patency rates compared to HeRO® Graft [8-9]. However, economic analyses indicate that the HeRO® Graft is more cost-effective over time, with a lower 1-year average cost 10 and reduced infection rates in certain cases[8], making it a favorable option for complex vascular access scenarios. During clinical evolution, our patient faced systemic complications, including septic shock, infectious endocarditis caused by Staphylococcus aureus, and aspiration pneumonia. As with any prosthetic vascular access devices, the HeRO® Graft carries an inherent risk of infection that may contribute to systemic events, although in this case a direct causal relationship with the device could not be confirmed.

In this case, the decision to use the HeRO® Graft in an axillo-femoral configuration was driven by the patient's anatomy and lack of other viable access sites. While unconventional, this approach proved effective in maintaining adequate dialysis access. The case highlights how innovative adaptations of existing technologies, guided by individualized vascular access planning, can address the complex needs of patients requiring long-term hemodialysis. As a limitation, functional dialysis parameters such as blood flow, dynamic venous pressure, and adequacy measures like Kt/V were not documented in this case. Future studies or larger case series should incorporate these variables to provide a more comprehensive evaluation of access performance.

Conclusion

This case demonstrates the feasibility of an axillo-femoral configuration for the HeRO® Graft, offering a novel solution for ESKD patients with limited vascular access options and expanding the device's potential applications. Despite the success of our approach, the long-term outcomes of this configuration remain unknown, and further studies are necessary to evaluate its durability, safety, and broader applicability.

Ethical considerations

All procedures in this study followed the ethical standards of the 1964 Helsinki Declaration and its later amendments. The research ethics committee at Fundação do ABC, approved this study under protocol number 7.569.490 and certificate of presentation of ethical appreciation number 86853525.9.0000.0082.

Consent to participate

Written informed consent was obtained from the patient for the publication of this case report.

Consent for publication

Written informed consent was obtained from the patient for the publication of this case report.

Declaration of conflicting interests

The authors declare no conflicts of interest in relation to the scientific content of this article. 

Funding statement

The authors received no financial support for the authorship of this article and had full editorial control of the paper.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.