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Introduction: For access-challenged patients with bilateral upper extremity central venous stenosis, solutions include the Hemodialysis Reliable Outflow (HeRO) device or an autogenous AV fistula in the lower limb. We evaluated HeRO grafts and transpositions of the femoral vein in maintaining primary and secondary patency., Methods: We retrospectively analyzed 40 patients with a HeRO device and 18 patients with superficial femoral artery to transposed femoral vein autogenous arteriovenous fistula (SFA-tFV). All patients had bilateral central venous obstruction. All procedures were outpatient performed by a single surgeon at one center between 2009-2015. Operative details, intraoperative flows, and flows at the first-week postoperative visit were analyzed, as were primary and secondary patency and intervention rates. Complications were compared between groups., Results: The one-year cumulative primary patency was 30% for HeRO grafts and 79% for SFA-tFV fistulas (p = 0.0001); secondary patency was 71% for HeRO grafts and 93% for SFA-tFV fistulas (p = 0.03). To maintain patency, HeRO patients required a mean 2.1 interventions per year and thigh fistula patients required a mean 0.4 interventions per year. Thirty-seven percent of thigh fistula patients had a hematoma or seroma versus 5% of HeRO patients and 17% of thigh fistula patients experienced delayed wound healing versus 2.5% of HeRO patients (p<0.05). None of the thigh fistula patients had distal ischemia., Conclusions: HeRO patients had lower primary and secondary patency rates versus thigh fistula patients and HeRO grafts required five-fold more interventions to maintain secondary patency. However, patients with thigh fistulas had significantly more wound healing problems. Thus, the SFA-tFV has become our access of choice for patients with bilateral central venous stenosis.

Purpose: This study was conducted to determine whether volume flow rate at the first postoperative visit could predict early failure of radiocephalic arteriovenous fistulas (RCAVFs)., Methods: We retrospectively studied the records of 264 patients who received a RCAVF between 2007 and 2013 at our centers. Data collected included patient demographics, medical history, arterial and venous mapping, and volume flow rate intraoperatively after fistula creation but before closing the surgical incision. An intraoperative flow rate &gt;100 mL/minute was targeted. We measured volume flow at the first postoperative visit 1 week after surgery and thereafter as needed., Results: Intraoperative flow was not a significant predictor of primary patency (p = 0.44) but flow at the first postoperative visit was a statistically significant predictor of fistula primary patency (p = 0.002). No fistula with a blood flow &lt;200 mL/minute at the 1-week postoperative visit reached maturity without receiving a maturation procedure. The hazard ratio for the first follow-up flow (mL/min) was 0.9973 (95% CI 0.9956, 0 .9989), indicating that for every 100 mL increase in blood flow the primary patency increases by 10%., Conclusions: Flow rate at the 1-week postoperative visit was the most important predictor of RCAVF patency. Thus, it should be possible to identify patients who would benefit from early intervention or closer follow-up as soon as the first postoperative visit. This should help reduce the use of bridging hemodialysis catheters and minimize the risks of catheter dependency.