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Abstract: SA-PO1144

A Unique Case of Persistent Hypoxia in a Post-Kidney Transplant Patient due to Occlusion from Hemodialysis Reliable Outflow Graft Causing Right to Left Shunt

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical


  • Connery, Michael, Westchester Medical Center, White Plains, New York, United States
  • Kareem, Samer, Westchester Medical Center, White Plains, New York, United States
  • Chugh, Savneek S., Westchester Medical Center, White Plains, New York, United States

The Hemodialysis Reliable Outflow (HeRO) vascular access graft is a method of vascular access able to bypass a central venous occlusion. Cannulas within the superior vena cava (SVC) can lead to occlusion and syndromes such as SVC syndrome, subclavian steal and esophageal varices. We report a unique case of a chronically occluded HeRO graft in a renal transplant patient causing SVC occlusion leading to right to left shunting and hypoxia.

Case Description

A 56 year-old woman presented with worsening shortness of breath and documented hypoxia. She also had left arm weakness without swelling. She had a history of ESRD with HeRO graft which connected her left brachial artery to the left internal jugular vein and emptied into the IVC. It had not been used for 10 years since her first kidney transplant. The graft had occluded. A TTE with bubble study revealed bubbles in the left heart when injected in the left arm after Valsalva concerning for right to left shunt. Her HeRO graft was obstructing the SVC, left brachiocephalic vein (BCV), and left subclavian vein and she was found to have a persistent vein of Marshall with Cardinal vein extending from the mid portion of the BCV to the left superior pulmonary vein. The proximal section of the HeRO graft was removed and endarterectomy with patch angioplasty were performed on the BCV and SVC and the cardinal vein was ligated. After surgery her hypoxia had resolved.


This is a case of a complication of long-term unused vascular access in a renal transplant recipient. Vascular occlusion is a common complication of indwelling catheters but can produce atypical symptoms. We have not been able to find any similar case studies of central occlusion induced hypoxia. This was a result of a shunt from abnormal vasculature that worsened with progressive obstruction of the left brachiocephalic vein. Removal of the offending catheter and ligation of the shunt cured the patient of her presenting symptoms. Detailed coordination between cardiology, vascular surgery, cardiothoracic surgery, and renal teams was vital for diagnosis and management.