title: From ZeRO to HeRO: Saving lives one HeRO at a time.
abstract: BACKGROUND
  This case report intends to highlight the Haemodialysis Reliable Outflow (HeRO) graft as a potential long term option for ongoing dialysis in patients with central venous stenosis.
  
  
  METHODS
  A 55year old patient, who developed end stage renal failure (ESRF) after chemotherapy treatment for breast cancer, presented at the limit of her dialysis access after a 15year haemodialysis history causing central vein stenosis. The patient was initially started on peritoneal dialysis but after repeated peritonitis was switched to haemodialysis. Over fifteen years of haemodialysis the patient had fistulae created in all four limbs. She had multiple tunnelled neck lines and developed an occluded left brachiocephalic vein and stenosed superior vena cava. Catheter dialysis via the right internal jugular vein was attempted but proved increasingly problematic due to poor clearances and frequent catheter changes. A further attempt was made to treat with peritoneal dialysis, but again, this was unsuccessful. As the patient had two failed attempts at peritoneal dialysis, had exhausted all her peripheral access options, and was having problematic catheter dialysis, she was offered the option of the HeRO graft as a 'last resort'.
  
  
  CONCLUSIONS
  The HeRO graft is a fully subcutaneous vascular access system that bypasses the central venous system providing haemodialysis access for patients with central venous stenosis. It consists of an arterial graft component and a venous outflow component, which are connected via a titanium connector. The central vein stenosis/occlusion is stented with insertion of the graft in to the right atrium, which is then secured to the arterial component for needling. So that successful dialysis could be completed as soon as possible post-operatively, the HeRO graft, in this instance, was combined with an immediate needling graft (Acuseal). This allowed the patient to receive successful dialysis within hours of completing the procedure.
  
  
  CONCLUSIONS
  This patient had reached the end of her haemodialysis life with no other options available. She was treated successfully with the HeRO graft, which at two months was patent and problem free. The patient had been able to return to work for the first time in 15 months. Utilising the HeRO graft in this way may provide new, potentially long term, options for safe and effective dialysis in patients with central venous stenosis.
authors: The James Cook University Hospital, Marton Road, Middlesbrough, United Kingdom. Electronic address: charlotteratcliff@nhs.net.
authors: Dr Charlotte
authors: DC
authors: Ratcliff
authors: The James Cook University Hospital, Marton Road, Middlesbrough, United Kingdom. Electronic address: m.hansrani@stees.nhs.uk.
authors: Miss Monica
authors: MM
authors: Hansrani
keywords: Arteriovenous graft; Central venous stenosis; Dialysis; End stage renal failure; Haemodialysis reliable outflow graft