A HeRO graft (Hemodialysis Reliable Outflow graft) is a specialized vascular access device designed for dialysis patients who have run out of conventional options. It connects an artery in the arm directly to the heart, bypassing blocked or damaged veins that would normally be used for dialysis access. The device is specifically built for patients whose central veins have become too narrowed or occluded to support a standard fistula or graft.
How a HeRO Graft Works
The system has two connected components that work together to create a reliable path for dialysis needles.
The first is the venous outflow component, a silicone tube about 5 millimeters wide, reinforced with a flexible metal framework made of nitinol (the same material used in many stents). This piece is threaded through the veins and positioned so its tip sits inside the right atrium of the heart. By reaching all the way to the heart, it bypasses any blockages in the chest veins that would prevent blood from flowing back during dialysis.
The second component is the graft itself, made from ePTFE, a synthetic material commonly used in vascular grafts. This portion is tunneled under the skin of the upper arm and connected to an artery on one end. On the other end, it connects to the venous outflow component. Together, the two pieces create a continuous loop: blood flows from the artery, through the graft (where it can be accessed by dialysis needles), and back toward the heart through the internal tubing.
Who Needs a HeRO Graft
Most dialysis patients start with a fistula, a direct surgical connection between an artery and a vein in the arm. When fistulas fail or can’t be created, a standard synthetic graft is the next step. But after years of dialysis, repeated catheter placements, and multiple surgeries, the large veins in the chest and upper body can become scarred, narrowed, or completely blocked. This is called central venous occlusion, and it makes traditional access impossible because blood has no clear path back to the heart.
At that point, many patients end up dependent on dialysis catheters, which carry a significantly higher risk of serious bloodstream infections. The HeRO graft exists to give these patients a catheter-free option. Current clinical practice guidelines from KDOQI (the major kidney disease guideline body) list the HeRO graft as an option when all upper extremity access sites have been exhausted and the patient is expected to need dialysis for more than a year. It sits alongside lower extremity fistulas and grafts as a late-stage choice, selected based on individual circumstances.
The Placement Procedure
HeRO graft placement is a surgical procedure, typically performed under general or regional anesthesia. The venous outflow component is inserted first. A surgeon threads it through a target vein, guiding it into position in the right atrium using imaging. The graft component is then tunneled under the skin of the arm and connected to a suitable artery, usually in the upper arm. The two components are joined together beneath the skin.
One practical advantage of the HeRO graft is how quickly it can be used. While a surgically created fistula often needs weeks or months to mature before it’s ready, a HeRO graft can be functional within 72 hours of placement in some cases. This means patients may be able to have their catheter removed much sooner, reducing infection risk during the transition period.
Long-Term Performance
Like all dialysis access options, HeRO grafts require ongoing maintenance. The numbers reflect this reality: overall primary patency (the graft working without any additional procedures) is about 33% at one year. That means roughly two-thirds of patients will need at least one intervention, such as a clot removal or a procedure to reopen a narrowed section, within the first year.
Secondary patency, which measures how long the graft continues to function with the help of maintenance procedures, is considerably better at about 69% at one year. This is an important distinction. The graft doesn’t necessarily fail after a complication. It often just needs a tune-up. For patients who would otherwise be stuck with a catheter, that trade-off is generally favorable, since catheters carry higher rates of infection, hospitalization, and even death.
Common Complications
The most frequent problem after HeRO graft placement is graft thrombosis, a blood clot that blocks flow through the graft. This is also the most common complication with standard dialysis grafts, so interventional radiologists and vascular surgeons are well-practiced at treating it. Thrombosis typically requires a procedure to clear the clot and restore flow, and it can happen more than once over the life of the graft.
Other potential issues include narrowing at the connection points (which restricts blood flow and triggers poor dialysis performance), infection of the graft material, and steal syndrome, where the graft diverts too much blood away from the hand, causing coldness, pain, or numbness in the fingers. Because the venous outflow component sits inside a major vein and extends to the heart, there is also a small risk of component migration, where the internal tubing shifts out of its intended position.
Living With a HeRO Graft
From a patient’s daily perspective, a HeRO graft functions much like a standard dialysis graft. Dialysis nurses access it by placing two needles into the graft portion in the arm, the same way they would with any other graft. The internal venous component is not accessed directly and requires no routine care from the patient.
You’ll need regular monitoring to catch problems early. Signs that something may be wrong include swelling in the arm, difficulty during dialysis sessions (alarms, poor blood flow, prolonged bleeding after needle removal), or any redness, warmth, or drainage near the graft site. Surveillance with periodic flow measurements or imaging helps detect narrowing before it leads to a complete clot.
For patients who have been through multiple failed access attempts and long stretches on a catheter, the HeRO graft represents a meaningful step up in quality of life. It eliminates the external catheter, reduces infection risk, and provides a durable access point that can be maintained over time with routine interventions.