History of vascular access for haemodialysis - Shunt

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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
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