A rare case of hemorrhage from spontaneous disconnection of super-HeRO adapter and early-cannulation graft: A case report

To overcome the limitations of central venous occlusion or stenosis (CVO) in complex chronic hemodialysis patients, the Hemodialysis Reliable Outflow (HeRO) vascular access graft was created as an alternative means of vascular access that bypasses the CVO and provides an additional upper extremity access option. The super-HeRO adapter was created to allow for the use of early cannulation grafts in the HeRO graft thereby enabling early cannulation and reducing tunneled dialysis catheter dependence time. Some complications have been previously reported for the traditional HeRO and the modified HeRO grafts. We report, a complication of spontaneous and delayed dehiscence/disconnection of the arterial graft from the venous outflow of a modified HeRO graft leading to massive hemorrhage. This complication has never been reported in literature. Our patient suffered this complication 4 weeks after implantation without any known inciting events. While it is unclear why this complication occurred, we must consider potential factors such as technical error of securing the arterial graft to the super-HeRO adapter coupler. Management involved immediate graft ligation given that the patient was in extremis upon presentation. Although deviations from instructions for use (IFU) are common in vascular surgery, particularly in endovascular cases for dialysis access, peripheral arterial disease, and aortic aneurysms, we recommend strict adherence to IFU for HeRO graft placement. Although rare, the sequalae of coupler dehiscence can be catastrophic and even fatal. Despite this complication, modification of the HeRO graft with the super-HeRO adapter remains a safe and feasible approach for establishing upper extremity dialysis access in complex ESRD patients with central venous pathology; we strongly caution that these cases should be performed in strict adherence with IFU using a 6 mm graft and the support seal system.