History of vascular access for haemodialysis - Shunt

Nephrol Dial Transplant (2005) 20: 2629–2635doi:10.1093/ndt/gfi168Advance Access publication 4 October 2005Historical Note(Section Editor: G. Eknoyan)History of vascular access for haemodialysisKlaus KonnerMedizinische Klinik I, Krankenhaus Ko¨ln-Merheim, Ko¨ln, GermanyAbstractThe history of vascular access is a history of vascularsurgery as well as a history of dialysis therapy. Thissurvey is a personal view on the history of vascularaccess without the ambition to cover every detail,but with an effort to mention the major steps in afascinating panorama.How it all started1896Jaboulay and Briau (Lyon, France) published anexperimental technique in dogs which consistedof suturing an artery-end-to-end-anastomosis. Theauthors already mentioned technical details proposedagain in current literature, e.g. the eversion of thesuture, an essential tool against thrombosis (Figure 1)[1]. A few years later, Alexis Carrel, who grew upin Lyon, later moved to Chicago, Baltimore andNew York, introduced the three-point end-to-endanda side-to-side-anastomosis, a milestone and stillused today (Figure 2) [2]. Carrel was awarded theNobel Prize in 1912.1924In October 1924, Georg Haas (Giessen, Germany)performed the first haemodialysis treatment in humanswhich lasted 15 min. He was supported by a grantfrom the Rockefeller Foundation. He first used glasscannulae to obtain arterial blood from the radialartery, which he returned to the cubital vein. Later heperformed a surgical cut-down to place a cannula intothe radial artery and into an adjacent vein. Asan anticoagulant, he initially used a purified hirudinpreparation which nevertheless caused severe reactionsso that from 1927 onward hirudin was replaced by theCorrespondence and offprint requests to: Klaus Konner,Medizinische Klinik I, Krankenhaus Ko¨ln-Merheim, Ko¨ln,Germany. Email: klaus.konner@uni.koeln.denon-toxic heparin. Till 1929, he performed eleventreatments in uraemic patients. He did not continue,however, presumably because of the limited efficacyand the lack of recognition by his peers. He died in 1971having witnessed the arrival of modern haemodialysistechniques.1943Modern haemodialysis therapy started on 17 March1943, when Willem Kolff, a young doctor in the smallhospital of Kampen (The Netherlands), treated a29-year-old housemaid suffering from malignanthypertension and ‘contracted kidneys’. Kolff hadconstructed a ‘rotating drum kidney’ with the supportof Mr Berk, the director of the local enamel factory.First, Kolff used only venipuncture needles to obtainblood from the femoral artery and to reinfuse it bypuncturing a vein. Later, he performed surgical cutdownof the radial artery which caused severe bleedingduring heparinization. On 11 September 1945 the firstof his 17 patients survived, a 67-year-old woman withcholecystitis and sulphonamide nephrotoxicity. Kolffleft the Netherlands in 1950 and continued to work inthe field of artificial organs in the USA.In the years that followed, substantial technicaldevelopments are linked to the names of Nils Alwall inLund (Sweden) and John P. Merril in Boston (USA).In the 1950s, the technical devices were available forregular haemodialysis treatments, e.g. Kolff ’s so-calledtwin-coil kidney [3] – but, the Achilles heel was areliable access to the circulation for multiple use whichdid not yet exist.The pioneers of maintenance haemodialysis1960In 1949, Allwall tried to use a rubber tubing and glasscannula device to connect artery and vein, but he failed.This idea of Alwall was later taken up by Quinton,Dillard and Scribner (Seattle, USA) who developedan arteriovenous (AV) Teflon shunt [4]. Only 10 weeksDownloaded from http://ndt.oxfordjournals.org/ by guest on February 20, 2012ß The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.For Permissions, please email: journals.permissions@oxfordjournals.org

2630 K. KonnerFig. 1. Animal experiments with vascular anastomoses by Jaboulay and Briau, published 1896 [1].Fig. 2. Three-point-end-to-end anastomosis by Carrel, published1912 [2].after the first patient, Clyde Shields, had been takenon maintenance haemodialysis, Scribner published a‘Preliminary report on the treatment of chronic uremiaby means of intermittent hemodialysis’, which describedwith clairvoyance some medical problems plaguingrenal replacement therapy still today: malnutrition,hypertension, anaemia and others [5]. Clyde Shields,a Boeing machinist, survived for 11 years after theinsertion of his first AV shunt on 9 March 1960.Two thin-walled Teflon cannulas with tapered endswere inserted near the wrist in the forearm, one into theradial artery and the other into the adjacent cephalicvein. The external ends were connected by a curvedteflon bypass tube. Later, the Teflon tube was replacedby flexible silicon rubber tubing.Scribner wrote in 1990: ‘Successful treatment ofClyde Shields represents one of the few instances inmedicine where a single success was required to validatea new therapy’ [6]. The development of a permanentvascular access by the Seattle group was the decisivebreakthrough, which made maintenance dialysispossible. It is rightly considered a landmark in thehistory of dialysis: maintenance haemodialysis therapybegan on 9 March 1960. Many variants of the AV shuntcame into use during the following years when themajority of AV-shunt insertions concerned temporaryvascular access at the start of chronic dialysis therapyto bridge the time when an AV fistula was absentor maturing.During early 1970s, TJ Buselmeier andco-workers (Minneapolis, USA) developed a compactU-shaped silastic prosthetic AV shunt with either oneor two Teflon plugged outlets which communicated tothe outside of the body. The U-shaped portion couldbe totally or partially implanted subcutaneously [7].This modification of the Scribner AV shunt gainedsome acceptance during the following years, especiallyfor paediatric haemodialysis patients.1961At that time, Stanley Shaldon (London, UK) facedthe problem of finding a surgeon willing to operate onthe radial artery and cephalic vein to introducecannulae for circulatory access. To become independent,Shaldon introduced hand-made catheters intothe femoral artery and vein by the percutaneousDownloaded from http://ndt.oxfordjournals.org/ by guest on February 20, 2012

History of vascular access for haemodialysis 2631Seldinger technique for immediate vascular access [8,9].Over time, vessels in different sites were used, includingthe subclavian vein. Shaldon concluded: ‘Eventually,veno-venous catheterization was preferred because thebleeding from the femoral vein was less than from thefemoral artery when the catheter was removed’ [10].Regional heparinization was practised with hexadimethrinebromide (‘Polybrene’) to neutralize the anticoagulanteffect of heparin. Obviously, these cathetersare not identical with the widely used type of cathetersfor temporary access, which today are usually called‘Shaldon catheters’.1962James E. Cimino and Michael J. Brescia (New York,USA) described a ‘simple venipuncture for hemodialysis’based on the experience of Dr Cimino whenhe worked part-time as a student at the BellevueTransfusion Center in New York [11]. After priorinfiltration of the overlying skin with 1% procaine, themost accessible forearm vein was punctured with aneedle. Needle sizes varied from No. 16 to No. 12gauge. Patency of the vein and adequate blood supplywere assured by application of tourniquet pressurewith a sphygmomanometer. A blood flow in the rangeof 150 and 410 ml/min was obtained in these mainlyfluid overloaded patients.1963Thomas J. Fogarty from Cincinnati, USA, inventedan intravascular catheter with an inflatable balloonat its distal tip designed for embolectomy andthrombectomy – an essential device even today [12].1966The legendary paper ‘Chronic hemodialysis usingvenipuncture and a surgically created arteriovenousfistula’ was published by Brescia, Cimino, Appell andHurwich [13]. Dr Appell was the surgeon in the team.The first surgically created fistula for the purposeof haemodialysis was placed on 19 February 1965,followed by further 14 operations as of 21 June 1966.Twelve out of these 14 AV fistulae resumed primaryfunction without complications, two never functioned(in the first patient, the anastomosis ‘was made toosmall’). This represents an early failure rate whichwould be admirably low even in 2005. Dr Scribnerfrom Seattle was the first nephrologist to refer oneof his patients to New York for the creation of anAV fistula.Dr Appel had performed a side-to-side-anastomosisbetween the radial artery and the cephalic antebrachialvein at the wrist after a 3–5 mm incision had been madein the corresponding lateral surfaces of the artery andthe vein. The suture was achieved using arterial silk incontinuous fashion.Many years later, in 1994, Dr Cimino stated that‘the decision to connect an artery and vein subcutaneously,thus creating an internal shunt, appeared notonly logical but was the classic example of necessityas the mother of invention’ and ‘that arteriovenousfistulas could lead to heart failure, and this would beparticularly hazardous in patients whose cardiovascularsystems were already compromised’ [14].Drs Cimino and Appell left the VeteransAdministration Hospital, Bronx, New York, a fewyears later: Dr Cimino is still busy practising palliativemedicine at the Calvary Hospital, Bronx, New York;Dr Appell has retired after a successful careeras a ‘countryside’ general surgeon in the greaterNew York area [Personal communication, April 2005].1967One year after the article of Brescia and Cimino,M. Sperling (Wu¨rzburg, Germany) reported thesuccessful creation of an end-to-end-anastomosisbetween the radial artery and the cephalic antebrachialvein in the forearm of 15 patients using a stapler [15].This type of AV anastomosis gained widespreadacceptance during the next decade, mainly based onthe rationale to restrict the inflow of blood into the AVfistulae to the flow provided by the feeding radialartery. The creation of an end-to-end anastomosis wastechnically challenging; an additional problem arosebecause the diameters of artery and vein were different;various patch techniques were tried to solve thisproblem. Because of the increasing numbers of elderly,hypertensive and diabetic patients with difficultvessels and high risk of a steal syndrome, this typeof AV fistula was abandoned as the first vascularaccess of choice. End-to-end-anastomoses are still awell established technique in revision procedures. Thestapler, however, never was accepted as a routinetechnical tool.For the transluminal recanalization of arteriesobstructed by atherosclerotic plaques Charles T.Dotter and co-workers (Portland, USA) introduceda type of balloon catheter. The first angioplastyrepresented an essential contribution to resolve oneof the great problems in vascular surgery and vascularaccess surgery [16].1968Lars Ro¨hl from Heidelberg, Germany, publishedhis results in 30 radial-artery-side-to-vein-endanastomoses[17]. After completion of the anastomosis,the radial artery was ligated distal to theanastomosis, thus resulting in a functional end-toend-anastomosis.With this technique, an antebrachialcephalic vein located at a more lateral position whichwould not have been suitable for a side-to-sideanastomosis,could be used successfully. Later on,the ligation of the peripheral arterial limb only waspractised in patients with impending signs of peripheralischaemia.Today, the artery-side-to-vein-end-anastomosishas become a standard procedure. The handling ofDownloaded from http://ndt.oxfordjournals.org/ by guest on February 20, 2012

2632 K. Konnerthe ‘free end’ of the vein should not be underestimated,however. Torsion and kinking of the vessel unfortunatelyare common errors that predispose to fistulafailure.1969In 1952, the French anatomist Robert Aubaniac, livingin Algeria, had described the puncture of the subclavianvein [18]. After the first use of the subclavian routefor haemodialysis access by Shaldon in 1961, thistechnique was adapted by Josef Erben from the formerCzechoslovakia, using the infraclavicular route [19].In addition, this catheter permitted to control centralvenous pressure in dehydrated, oliguric haemodialysispatients. During the following two decades thesubclavian approach was the preferred route fortemporary vascular access by central venous catheterization.Today, time has come to abandon subclaviancannulas in patients with chronic renal disease, sincephlebographic studies revealed a 50% stenosis orocclusion rate at the site of cannulation. This predisposesto oedema of the arm, especially after creation ofan AV fistula [20].Based on animal experiments, George I. Thomasfrom Seattle, USA, presented his ‘Dacron appliqueshunt’ in 10 patients [21]. The idea was to eliminateall intraluminal foreign body, thus avoiding any areapredisposing to thrombus formation. The authorsutured oval Dacron patches to the common femoralartery and the saphenous/common femoral vein.The Dacron patches were connected with silastictubes and brought to the surface of the anteriorthigh approximately 10 cm distal to the femoralwound. In desperate cases, some groups still use theThomas-shunt [22].For patients with lack of or exhaustion of peripheralveins, a new idea came up: Gilberto Flores Izquierdo(Mexico City) [23] and James May (Sidney, Australia)[24] proposed to remove the segment of the saphenousvein between groin and knee and to connect it in aU-shaped fashion in the elbow region with thebrachial artery and a suitable vein. As a variant it wasproposed to implant the totally mobilized vein to thegreat vessels in the thigh or to anastomose the distallymobilized saphenous vein to the femoral artery.The first step of using a graft in vascular accesssurgery was done. In 1970, Roland E. Girardet fromNew York, USA, analysed his results with this noveltechnique [25].femoral artery was exposed, the musculus sartoriuswas mobilized. Both ends of the musculus sartoriuswere passed underneath the exposed artery and joinedagain. The fascia lata was closed, ensuring thatproximal and distal openings of the fascia weresufficiently large to prevent compression of the artery.Seventeen patients had undergone this proceduresuccessfully.The first clinical results with a mandril graft werereported by Charles H. Sparks (Portland, USA) basedon a series of animal experiments starting in 1965 [27].He implanted a silicone mandril assembly consisting ofa silicone rubber rod with a covering of two speciallyprepared siliconized knitted Dacron tubes. It was leftin place for 6 weeks so that the Dacron mesh becameorganized after invasion of the surrounding tissue. Themandril was then removed and the endings of thematured subcutaneous tunnel were anastomosed tothe native vessels. The first report on the use inhaemodialysis patients was given by Beemer in 1973[28]. Because of the unfavourable results and theavailability of more successful prosthetic materialsthis technique was abandoned a few years later.1971G. Capodicasa from Naples (Italy) posed the question‘Is a shunt an indispensable requirement for repeatedhaemodialysis?’ and presented his technique ofmobilizing and fixing the radial artery underneath theskin thoughout its length along the forearm [29], butthere were no further publications to confirm the valueof this procedure.The first idea to implant a plastic valve as circulatoryaccess was reported by W.D. Brittinger (Figure 3).Downloaded from http://ndt.oxfordjournals.org/ by guest on February 20, 2012New ideas1970A ‘16 month’s experience with the subcutaneously fixedsuperficial femoral artery for chronic haemodialysis’was published by W.D. Brittinger (Mannheim,Germany) [26]. Following a femoral arteriogram toexclude arterial anomalies or disease, the superficialFig. 3. Plastic valve, experimentally implanted into a femoralartery, published 1971 [31] (courtesy of Prof. W.D. Brittinger,Neckargemu¨nd, Germany).

History of vascular access for haemodialysis 2633In an animal model, he inserted a massive silasticcylinder with a Dacron skirt end-to-side into a sheepcarotid artery. The implantation of this device into ahuman superficialized femoral artery was planned, butunfortunately not realized [30].New types of graftshad already published this ‘retrograde venography’technique in AV shunts and fistulas 1 year beforein a German radiologic journal [36].Andreas Gru¨ntzig from Zu¨rich, Switzerland,continued the work of Dotter using the then newcatheter technique to recanalize chronic arterial occlusions,the basis of modern angioplasty [37].1972The year 1972 saw the introduction of three new graftmaterials, one biologic and two synthetic.A modified bovine carotid artery biologic graft(Artegraft, Johnson & Johnson), a product of researchby D.M.L. Rosenberg, was introduced for constructionof vascular access in eight haemodialysis patientsby Joel L. Chinitz [31] (Philadelphia, USA). It wasthe first xeno-graft and received some acceptanceduring the 1970s.T. Soyer (Denver, USA) used expanded polytetrafluoroethylene(ePTFE) in animal experiments toreplace various major thoracic and abdominal veins[32]. In 1976, L.D. Baker Jr (Phoenix, USA) presentedthe first results with expanded PTFE grafts in 72haemodialysis patients [33]. The majority of thesegrafts were 8 mm in diameter. Numerous publicationsduring the subequent years demonstrated the valueand the limitations of this prosthetic material, whichhas remained the first choice of grafts for vascularhaemodialysis access even today.Irving Dunn (Brooklyn, NY, USA) had chosen adacron velour vascular graft for creation of AV bridgegrafts, initially in animal experiments and then in auraemic female patient [34]. Subsequently, this materialdid not yield satisfactory results for vascular access,although in other fields of vascular surgery it hasbecome well accepted as graft material.The fact that Dacron was not accepted and thatePTFE continues to be the material of choice highlightsthe fact that in the field of vascular access specialcriteria must be met by the graft material: apart fromsafety and ease of handling during the operation, inaddition, no formation of aneurysms after repeatedcannulation and low infection rates are required; easysurgical replacement of graft segments in cases ofinfected and aneurysmatic grafts is another importantprerequisite.1973T.W. Staple (St Louis, USA) described a novelangiographic technique in his paper ‘Retrogradevenography of subcutaneous arteriovenous fistulascreated surgically for hemodialysis’ [35]. During subsequentyears, further substantial contributions camefrom the St Louis group with Louis A. Gilula, theradiologist, and Charles B. Anderson, the vascularsurgeon. This angiographic technique is still usedtoday, preferably in combination with the digitalsubtraction device. M. Thelen (Bonn, Germany)1976Two authors had worked for a few years with a newgraft material: the human umbilical cord vein becauseof the perceived advantages of an antithrombogenicintimal inner surface and the absence of valves andbranches. B.P. Mindich (New York) used chemicallyprocessed umbilical cord veins without external support,whereas H. Dardik (New York) surrounded thegraft with a polyester fibre mesh [38,39]. This materialnever achieved a real breakthrough because of insufficientresistance against the trauma of repeatedcannulation and of problematic surgical revision inthe case of aneurysm and infection.1977A group from Chicago with Dr Gracz as first authorpublished an article on ‘Proximal forearm fistulafor maintenance hemodialysis’, a variant of an AVanastomosis. They sutured the perforating vein to theproximal radial, ulnar or brachial artery [40]. Recently,a modification of this type of AV fistula gained someimportance as a vascular access in the old, hypertensiveand diabetic patients because it permits a proximalanastomosis with a low risk of hypercirculation, asblood flow is limited by the finite diameter of theperforating vein (3–5 mm) [41].1979A.L. Golding and co-workers (Los Angeles, USA)developed a ‘carbon transcutaneous hemodialysisaccess device’ (CATD), commonly known as ‘button’,as a blood access not requiring needle puncture [42].The device consisted of two components: a vitreouscarbon access port sealed with a conical polyethyleneplug and a PTFE graft securely and smoothly attachedto the port. It could easily be connected with speciallyconstructed bloodlines. As a procedure of third choice,these devices were expensive and never gained widespreadacceptance.F.L. Shapiro (Minneapolis, USA) described anothertype of ‘button’, a device similar to that developedby Golding [43]. In 1983, J.L. Wellington (Ottawa,Canada) tried to implant these buttons along anarterialized, superficialized basilic vein – a promisingidea, but the results were disappointing [Personalcommunication, 1983]. Because only few groups usedthese devices, the experience remained limited.A remarkable publication came from Joseph L.Giacchino (Maywood, USA) discussing uncommonDownloaded from http://ndt.oxfordjournals.org/ by guest on February 20, 2012

2634 K. Konnertechniques like the reverse AV fistula, unusually locatedinterposition grafts and brachio-brachial arterioarterialgrafts[44].The first report on a new angiographic technique,known as digital subtraction angiography waspublished by David L. Ergun (Madison, USA):‘A hybrid computerized fluoroscopy techniquefor noninvasive cardiovascular imaging’. Later, thistechnique was adapted to visualize AV fistulas andprosthetic bridge grafts, using the arterial as well as thevenous route [45].Recent ideas1980–1992A highly informative paper was published by W.P. Geis,together with Dr Giacchino: ‘A game plan for vascularaccess for hemodialysis’ – a collection of innovative,creative ideas concerning arteriovenous fistulas as wellas graft insertion in various locations [46].The era of the percutaneous, transluminal angioplastyin vascular accesses started with a publicationof David H. Gordon and Sidney Glanz (New York,USA) based on the work of Gru¨ntzig: ‘Treatment ofstenotic lesions in dialysis access fistulas and shunts bytransluminal angioplasty’ [47].G. Kro¨nung (Bonn, Germany) published fundamentalideas on how different types of cannulation affectedthe remodelling of the venous arm of the fistula [48].He demonstrated that cannulation may not onlydestroy the vein, but is essential for remodelling.Thus, cannulation can be an effective tool to avoidthe formation of aneurysms and stenoses.In patients with exhausted vessel anatomy in botharms or stenoses along the subclavian vein resistant tointervention Jose´ R. Polo (Madrid, Spain) introducedthe concept of ‘brachial-jugular polytetrafluoroethylenefistulas for hemodialysis’ [49], a brilliant solutionfor the occasional patient who may profit fromcreation of a graft-vein-anastomosis using the internaljugular vein.While angiographic and interventional radiologictechniques became widely accepted, non-invasiveultrasound techniques, mainly used by nephrologists,were introduced only slowly. A landmark was thearticle of Barbara Nonnast-Daniel (Hannover,Germany) on ‘Colour doppler ultrasound assessmentof arteriovenous haemodialysis fistulas’ [50]. She wasable to obtain anatomic and functional parameters,which were useful to guide the surgeon for optimizingthe procedure in the first access operation, but alsouseful for surveillance and monitoring the functionof the access during follow-up.OutlookThe above remarks reflect the subjective assessmentof what we consider are the highlights in past efforts tooptimize the vascular access in haemodialysis patients.Knowledge of these ingenious, innovative, sometimeseven bold ideas, although not always successful, isstimulating and hopefully also useful to the physicianstruggling with the challenge to construct vascularaccesses nowadays. Creative efforts provided a varietyof solutions in the past and so, we are happy today toplay on more than one instrument.Vacsular access surgery has become an interdisciplinaryfield of modern medicine. Once it had beeninaugurated by pioneers in nephrology at a time whenaccess surgery was unknown in the then still youngdiscipline of vascular surgery. In the early 1970s, withthe increasing complexity of access related problems,nephrologists delegated the responsibilty for thevascular access more and more to their surgeons. Formany years, vascular access was regarded as anexclusively surgical problem. With the introduction ofnon-invasive preoperative mapping of blood vessels, ofearlier referral to nephrologists and to access surgeonsand of venous preservation, nephrologists must learnagain to assume responsibility for vascular access.Beyond the preservation of vessels in the predialyticphase, this includes surveillance and monitoring ofthe established access, but also aquiring up-to-dateknowledge on the surgical options and many otheraspects, but above all maintaining close cooperationwith surgeons and radiologists.What is required today is a completely newapproach to comprehensive access management thathas to escape from crisis management. History may behelpful.Acknowledgements. I am indebted to Prof. Eberhard Ritz,Heidelberg, Germany for insightful comments and review of themanuscript. Thanks also to Dr Dirk Hentschel, HavardMedical School, Boston, USA for providing the author withFigures 1 and 2.Conflict of interest statement. None declared.References1. Jaboulay M, Briau E. Recherches expérimentelles sur la suture etla greffe arte´rielles. Lyon Me´d 1896; 81: 97–992. Carrel A. Technique and remote results of vascular anastomoses.Surg Gynecol Obstet 1912; 14: 246–2543. Kolff WJ. First clinical experience with the artificial kidney. AnnInt Med 1965; 62: 608–6194. Quinton WE, Dillard DH, Scribner BH. Cannulation of bloodvessels for prolonged hemodialysis. Trans Am Soc Artif InternOrgans 1960; 6: 104–1135. Scribner BH, Buri R, Caner JEZ, Hegstom R, Burnell JM.The treatment of chronic uremia by means of intermittenthemodialysis: a preliminary report. Trans Am Soc Artif InternOrgans 1960; 6: 114–1226. Scribner BH. 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