This study aims at Hemodialysis Reliable Outflow (HeRO) grafts (Merit Medical, South Jordan, Utah) are used when venous outflow is inadequate to support a conventional access. These have been perceived as complex to implant and being associated with high infection and morbidity rates. Our results have been favorable, and during the past few years we have evolved a defined protocol for insertion that minimizes morbidity and maximizes efficiency. Our protocol includes staged intravenous access vs HeRO graft placement, reverse Trendelenburg positioning, subcutaneous access of the deep/clean portion of the existing catheter, use of a stiff wire placed within the inferior vena cava, dilation of the tract to 8 mm, device lubrication, direct visualization of all insertion procedures, and use of immediate access conduits with Super HeRO connector. Our results suggest that HeRO graft placement can be performed with minimal morbidity and mortality on an outpatient basis. Short-term infection rates are low (2%), which we ascribe to retrieval of the existing catheter deep to the cuff, and 89% of patients have their grafts immediately accessed and are discharged without a catheter.