History of vascular access for haemodialysis - Shunt

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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
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