Axillary necklace graft salvage of a locally infected Haemodialysis with Reliable Outflow (HeRO®) graft

A 48-year-old patient presented 4 months after insertion of a right sided Haemodialysis with Reliable Outflow (HeRO®, Merit Medical) graft with a discharging abscess at the site of the brachial artery anastomosis. There was localised involvement of the arterial Gore® Acuseal inflow graft that necessitated its removal. The venous outflow component was thought salvageable as infection was well localised to the region of the antecubital fossa.Alternative access options were limited so we sought to preserve the venous outflow portion of the patient's original graft - minimising tissue damage and avoiding the need for a dialysis line.The infected arterial graft was excised, leaving behind the original SuperHero® connector and venous graft. A left sided tunnelled axillary necklace technique was utilised to restore arterial inflow.After a four-day recovery, the patient went on to successfully resume their usual haemodialysis regimen without any complications. Convalescent imaging, repeat blood cultures, and monitoring of inflammatory markers showed no signs of residual infection at 6 weeks.The originality of this case was the way in which an axillary necklace inflow graft was connected to the pre-existing venous outflow portion of the HeRO® haemodialysis graft system, allowing the excision of the infected inflow graft at the brachial anastomosis. This technique could be viewed as an effective salvage procedure as it allowed the venous outflow portion of the original graft to remain in situ, minimised tissue damage and enabled the patient to swiftly resume haemodialysis without the need for a line.