Incidence and risk factors for hemodialysis access-induced distal ischemia after hemodialysis reliable outflow (HeRO) surgery

Abstract

Background:

Hemodialysis Reliable Outflow (HeRO) graft is vital for complex hemodialysis patients who have exhausted all other access options. Hemodialysis access-induced distal ischemia (HAIDI) is a serious complication, however, risk factors for HAIDI after HeRO graft operation are unknown.

Methods:

Institutional records were retrospectively reviewed for all index HeRO graft implantations performed between 2014 and 2023. Re-do HeRO grafts were excluded. Patient demographics, operative details, and postoperative outcomes were collected. Primary outcome was symptomatic HAIDI following HeRO surgery. Statistical analysis was performed using univariate tests, logistic regression analysis, and Kaplan-Meier estimates for patency.

Results:

Over the 10-year study period, 232 index HeRO surgeries were performed of which 23 (9.9%) developed symptomatic HAIDI. Patients with HAIDI were older than their counterparts (64.0 ± 13.7 vs 57.0 ± 13.3 y, p = 0.008). All other demographic factors and comorbidities were similar between groups (p = NS each). For inflow, patients with HAIDI more frequently underwent brachial artery anastomosis (78.3% vs 65.1%, p = 0.04), and less frequently utilized a prior arteriovenous graft or fistula (8.7% vs 25.8%, p = 0.04). The use of a tapered graft was similar between groups (47.8% vs 31.1%, p = 0.10). On multivariable analysis, only patient age (hazard ratio (HR) 1.06 per year, 95% confidence interval [CI], 1.02–1.10, p = 0.003) was independently associated with symptomatic HAIDI. Tapered graft utilization was not associated with reduced risk of HAIDI (HR 0.75, 95% CI, 0.23–2.38, p = 0.61). Patients with HAIDI had significantly higher 30-day hospital readmission rates (34.8% vs 17.7%, p = 0.0049) and reduced secondary graft patency rates (1-year, 46.0 ± 11.4% vs 71.3 ± 3.6%; 3-year, 23.7 ± 11.1% vs 44.0 ± 4.8%, p = 0.01).

Conclusion:

Symptomatic HAIDI is fairly common after HeRO graft implantation and portends inferior long-term outcomes with older age being the only associated risk factor. Tapered conduits were not associated with reduced risk of HAIDI. These data are valuable for informed consent and shared decision-making among patients undergoing HeRO graft surgery.