https://doi.org/10.1177/1129729818812357 The Journal of Vascular Access 1–3 © The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1129729818812357 journals.sagepub.com/home/jva JVA Te Journal of Vascular Access Editor HeRO grafts have a high rate of postoperative com- plications including development of steal syndrome, arm hematoma, graft blowout, and death. 1 One case of migration and prolapse of a HeRO graft into the right heart has been described with successful surgical removal. 2 Endobronchial forceps have been used to remove a variety of intravascular and extravascular for- eign bodies. 3 There are no reports in the literature of separation or endovascular retrieval of the separated venous outflow component of a HeRO graft. This report describes a case of graft separation occurring during a percutaneous thrombectomy procedure salvaged with endobronchial forceps. Institutional review board approval was not required for this report. A 40-year-old man with end-stage renal disease on hemodialysis for 17 years presented with right upper extremity arm swelling and occlusion of an upper extremity HeRO graft. Two months earlier, a right upper extremity hemodialysis circuit was placed using a HeRO graft given the patient’s central venous stenosis and prior occluded fistulas. One month after placement, the patient underwent percutaneous mechanical thrombectomy of the HeRO graft twice over a 2-week time period. The patient presented 1 week later with repeat occlusion of the graft. A third mechanical thrombectomy was attempted; however, during this attempt, the venous out- flow component of the HeRO graft separated from the arterial graft component with the proximal end migrating into the right internal jugular vein and the distal end ter- minating within the inferior vena cava (Figures 1, 2(a) and (b)). Surgical cut-down was considered given the 19-French size and inflexible nature of the HeRO graft; however, interventional radiology was consulted for pos- sible percutaneous removal. Access was obtained into the right common femoral vein under ultrasound using a micropuncture needle and following serial dilation, coaxial 26-French × 33 cm Percutaneous retrieval of a fractured HeRO graft venous outflow component with endobronchial forceps Nishant Patel 1 , Jawad Hussain 1 , Joseph J Gemmete 1 , Jeffrey Forris Beecham Chick 2 , Kenneth Woodside 3 and Ravi N Srinivasa 1 Date received: 14 May 2018; accepted: 25 July 2018 1 Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, MI, USA 2 Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, VA, USA 3 Department of Surgery and Division of Transplant Surgery, University of Michigan Health System, Ann Arbor, MI, USA Corresponding author: Ravi N Srinivasa, Division of Interventional Radiology, Department of Radiology, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. Email: medravi@gmail.com 812357JVA 0 0 10.1177/1129729818812357The Journal of Vascular AccessPatel et al. research-article 2018 Letter to the editor Figure 1. Frontal spot fluoroscopic image after first percutaneous mechanical thrombectomy showing an intact HeRO graft (white arrow).