Any running blood access depends entirely upon unobstructed venous outflow to the heart. Venous outflow of an Arteriovenous (AV) access can be obstructed at various levels, including the access outflow segment itself, the venous anastomosis of an Arteriovenous Graft (AVG), the swing segment of a Basilic Vein Transposition (BVT), or the cephalic arch peripherally. Outflow can also be obstructed more centrally. In the past two decades it has been increasingly recognized that the subclavian vein can be obstructed at the venous thoracic outlet, which most feel must be treated with bony decompression for lasting relief.

What of problems that occur even more centrally, in the chest? Venous anatomy in the chest is shown in Figure 1. On both sides the subclavian veins are joined by the internal jugular veins to create the brachiocephalic veins. Longer on the left, the brachiocephalic veins then merge to form the superior vena cava. Each of these vessels can be affected by various issues inherent in the provision of hemodialysis access (catheters and high flow) or other related problems (pacemaker leads, chemotherapy ports, and misadventure during cardiac surgery, for example), not forgetting natural anatomic variants producing extrinsic compression.

If one side only is obstructed, it may be most prudent to simply move to the other side. This gives up access options, however, and often aggressive attempts at correcting the problem are worthwhile to prolong use of the arm [1]. This topic is especially important today (2023), as several techniques and devices have recently become available to solve these problems.

In the early 2000s, John Gurley, an interventional cardiologist working in Kentucky, used the principle that the veins are anterior to the arteries (and brachial plexus) to create access by pushing a wire from the SVC (via the groin) through the skin of the neck superior to the clavicle. Termed “inside out,” this technique was first used to place pacemaker wires, but it was very quickly realized that catheter placement was the obvious next step [2,3]. Within the past few years, a commercial device (Surfacer System, Bluegrass Vascular Technologies, Inc., San Antonio, TX) has become available to very easily accomplish this. While this leaves a dialysis catheter in place, most surgeons follow this with conversion to a HeRO graft, either immediately or in a staged fashion [4,5].

The Surfacer device (Figure 2) “automates” this process in two ways. First, by means of a specially formed tip, it is advanced through the occluded SVC/right brachiocephalic system for several centimeters. Second, based on the degree of cranio-caudal imaging angulation required, a calibrated pre-shaped Nitinol needle guide is deployed to “point” the sharpened stiff wire toward a target previously placed on the skin. The wire is advanced by means of a plunger system, and if the equipment is lined up properly nothing seems to be happening – you are “staring down the barrel of the gun,” with the wire advancing directly toward the image intensifier – until the wire tents up the skin and ultimately pokes through it (https://bluegrassvascular.com/surfacer/). One drawback of this system is that the device is quite stiff, and thus only right femoral access with right sided neck exit is possible.

The “inside out” procedure (and several variants of recanalization above) are techniques for placing a dialysis catheter. In almost all cases this can be followed by HeRO graft placement. It is our sense that this began as a single-step procedure, but data emerged supporting the observation that the infection rate was lower if access and HeRO graft placement were staged [4]. In addition, we feel best results are obtained with the Surfacer device with the arms tucked to allow full tube rotation, and at least psychologically these are two non-trivial procedures. For all these reasons we favor staging the HeRO by two weeks or so, and using this technique have experienced an acute infection rate of only 2% [5]. As the HeRO uses the catheter tract for atrial access, of course, an immediate access graft must be used (or a femoral catheter placed).

As of June 2022, there have been a total of 12 studies describing outcomes in 124 patients (with seven undergoing a redo procedure). Results from the three “large” multicenter series (30, 30, and 32 patients) show a technical success rate of 95% and no technical complications [6-8]. Our single center results are quite similar. In 15 patients undergoing 17 procedures, our technical success rate of 100% and absence of complications adds further support to the safety and efficacy of this device. Further, redo Surfacer procedures appear to be quite feasible – in our two and the seven in one of the multicenter studies [7], no complications have occurred and technical success was again 100%.