Impact of Antiplatelet and Anticoagulation Therapy on Hemodialysis Reliable Outflow Graft Patency

Ann Vasc Surg. 2025 Dec:121:190-200. doi: 10.1016/j.avsg.2025.05.047. Epub 2025 Jun 3.

Abstract

Background: The Hemodialysis Reliable Outflow (HeRO) graft combines an arteriovenous graft with a central venous stent, allowing for hemodialysis access in patients with end-stage renal disease limited by central venous stenosis. The impact of anticoagulation (AC) and antiplatelet (AP) medications on HeRO graft patency is unknown.

Methods: Institutional medical records were retrospectively queried for all HeRO graft procedures performed from 2014 to 2023. Data were collected on demographics, medical comorbidities, operative details, and perioperative AC/AP medication use. The Cox proportional hazards model was used to identify risk factors for loss of primary patency.

Results: A total of 232 patients with end-stage renal disease underwent HeRO graft implantation across 3 hospitals, with a median follow-up of 1.5 years. Perioperative AC/AP strategies included mono-antiplatelet therapy (MAPT, n = 38 [16.4%]), dual-antiplatelet therapy (DAPT, n = 57 [24.6%]), AC only (n = 38 [16.4%]), MAPT with AC (n = 66 [28.4%]), DAPT with AC (n = 28 [12.1%]), and none (n = 5 [2.2%]). Direct oral anticoagulants were used in 85 patients (36.6%). There were no differences in bleeding or thrombotic complications between groups (symptomatic hematoma, P = 0.96; pulmonary embolism, P = 0.45). One-year primary patency rates were highest among patients on AP therapy (16.7 ± 6.2% [no AP] vs. 40.2 ± 5.4% [MAPT] vs 33.7 ± 5.6% [DAPT], log-rank P = 0.016). There was no difference with AC use (38.6 ± 5.4% [no AC] vs. 28.8 ± 4.3% [AC], log-rank P = 0.11). After adjusting for patient factors, MAPT (hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.35-0.83, P = 0.005) and DAPT (HR 0.64, 95% CI 0.41-1.01, P = 0.05) were protective of loss of primary patency, whereas AC (HR 1.07, 95% CI 0.76-1.50, P = 0.70) did not impact primary patency rates.

Conclusion: Among patients undergoing HeRO graft implantation, the use of antiplatelet medications was associated with improved primary patency rates.

Publication types

  • Multicenter Study

MeSH terms

  • Aged
  • Anticoagulants* / administration & dosage
  • Anticoagulants* / adverse effects
  • Arteriovenous Shunt, Surgical* / adverse effects
  • Arteriovenous Shunt, Surgical* / instrumentation
  • Blood Vessel Prosthesis Implantation* / adverse effects
  • Blood Vessel Prosthesis Implantation* / instrumentation
  • Female
  • Graft Occlusion, Vascular* / diagnostic imaging
  • Graft Occlusion, Vascular* / etiology
  • Graft Occlusion, Vascular* / physiopathology
  • Graft Occlusion, Vascular* / prevention & control
  • Humans
  • Kidney Failure, Chronic* / diagnosis
  • Kidney Failure, Chronic* / therapy
  • Male
  • Middle Aged
  • Platelet Aggregation Inhibitors* / administration & dosage
  • Platelet Aggregation Inhibitors* / adverse effects
  • Renal Dialysis*
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Stents
  • Time Factors
  • Treatment Outcome
  • Vascular Patency* / drug effects

Substances

  • Platelet Aggregation Inhibitors
  • Anticoagulants