Overcoming Central Venous Occlusion: The First HeRO Graft Procedure in the Baltic States

Background: Central venous occlusive disease is a major challenge in hemodialysis patients who have exhausted conventional vascular access options and may lead to long-term dependence on tunneled central venous catheters. The Hemodialysis Reliable Outflow (HeRO) graft provides an alternative by bypassing obstructed central veins and enabling catheter-free upper-extremity vascular access. Case presentation: We report the first HeRO graft implantation in Lithuania in a 78-year-old woman with end-stage kidney disease and extensive central venous occlusive disease. Previous arteriovenous fistulas had failed because of thrombosis and severe venous hypertension, while prolonged catheter dependence was complicated by recurrent infections, dislodgements, and multiple catheter exchanges. The HeRO venous outflow component was implanted through the existing tunneled catheter access and positioned in the right atrium. It was connected to an early-cannulation expanded polytetrafluoroethylene graft anastomosed to the brachial artery. Completion fistulography demonstrated unobstructed flow through the system into the right atrium. The procedure was technically successful, and the graft was successfully cannulated for hemodialysis 24 h after implantation, avoiding the need for temporary catheter placement. Conclusions: The HeRO graft may provide a valuable catheter-sparing option for carefully selected hemodialysis patients with severe central venous occlusive disease and no feasible conventional upper-extremity access. This case demonstrates its technical feasibility in a complex vascular access setting and highlights the potential role of an early-cannulation graft when immediate catheter removal is necessary.