title: Multidisciplinary team approach to end-stage dialysis access patients.
abstract: BACKGROUND
  The hemodialysis reliable outflow (HeRO) access device is a permanent dialysis graft used in patients with central venous obstruction. Given the complexity of care related to end-stage dialysis access (ESDA) patients, a multidisciplinary approach has been used to achieve operative success of HeRO graft placement.
  
  
  METHODS
  The single-center retrospective review included adult patients that were seen in ESDA clinic who underwent a HeRO graft placement from September 2010-September 2014 under the care of a team consisting of a nephrologist, an interventional radiologist, and a surgeon. The effectiveness of the multidisciplinary approach was evaluated using outcome variables including successful HeRO graft placement, operative complications, the rate of obtaining central venous access, and advanced endovascular maneuvers performed by interventional radiology to obtain central venous access.
  
  
  RESULTS
  A multidisciplinary approach has been used in 33 ESDA patients. Access to the right atrium was achieved in 100% of cases. Fifty-eight percent of patients required advanced endovascular maneuvers in the interventional radiology suite to obtain central venous access. Successful HeRO graft placement was achieved in 94% (31 of 33) of the study population. No intraoperative complications were encountered. Median primary and secondary patency rates were 83 d (interquartile range: 45-170) and 345 d (interquartile range: 146-579) per HeRO graft placement, respectively. Primary and secondary patency rates at 60 d were 70% (23 of 33) and 79% (26 of 33), respectively.
  
  
  CONCLUSIONS
  In this difficult patient population, a multidisciplinary team can provide a unique and collaborative approach to HeRO graft placement in patients with complex central venous outflow obstruction.
authors.affiliation: Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. Electronic address: clark.d.kensinger@vanderbilt.edu.
authors.forename: Clark
authors.initials: C
authors.lastname: Kensinger
authors.affiliation: Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Evan
authors.initials: E
authors.lastname: Brownie
authors.affiliation: Division of Interventional and Vascular Radiology, Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Peter
authors.initials: P
authors.lastname: Bream
authors.affiliation: Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Derek
authors.initials: D
authors.lastname: Moore
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000295:instrumentation / Q000379:methods*; D057510:Endovascular Procedures / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team; D006435:Renal Dialysis / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies
keywords: Dialysis access; HeRO graft; Hemodialysis reliable outflow dialysis device; Venous outflow obstruction