Fig. 1.1
The first hemodialysis machine used in the United States: the rotating drum artificial kidney. Top panel: the original Kolff rotating drum dialyzer (Image courtesy of Northwest Kidney Centers, Seattle, WA). Bottom panel: Kolff-Brigham rotating drum artificial kidney on display at Northwest Kidney Centers’ Dialysis Museum (Seattle, WA)
The First Arteriovenous Shunt
The prospect of living with end-stage renal disease (ESRD) became a reality on March 9, 1960, when a Teflon arteriovenous shunt made dialysis possible for a Boeing machinist, Clyde Shields, at the University of Washington in Seattle. Mr. Shields survived for 11 years on chronic hemodialysis (Fig. 1.2) [5]. The original shunt was developed as a result of the efforts of three people: Belding Scribner, the nephrologist, who came up with the concept; Wayne Quinton, the hospital engineer, who developed the technology; and Dave Dillard, the pediatric cardiac surgeon, who implanted the shunt. The story of developing the shunt is recalled by Scribner and colleagues as follows [6]:
Fig. 1.2
Belding Scribner (right) with Clyde Shields (left) (Image courtesy of Northwest Kidney Centers, Seattle, WA)
On February 9, 1960, a 42-year-old patient, Neil Ward, was transferred from Spokane to the University of Washington in Seattle in a near terminal condition from uremia and congestive heart failure or you to acute renal failure. He responded dramatically to intense dialysis and ultrafiltration, and within a week he was up and around and nearly normal health. Unfortunately, anuria made the diagnosis of reversible renal failure suspect, and a biopsy showed total renal destruction from rapidly progressive glomerular nephritis. The dilemma we face is well expressed in an expert from a letter we wrote to his referring physician on February 25, 1960: “We have had a tremendous problem in deciding in our own minds what the reasonable thing to do here. His wife has been most cooperative and understanding the dilemma, and she fully realizes the prognosis. The question was raised as to whether he should be returned to Spokane, but his wife said that she thought it would be better to keep him here. We have tried to be objective and discussing his case among ourselves, and have asked the question of whether we have the right to prolong his life in the fashion we have. It was our feeling that until we had the biopsy we could not be sure the prognosis, and we were unable to get a biopsy until we could get him in good enough shape to do so, hence from the point of view of the ethics of the case, we have considered the dialysis procedure part of our diagnosis procedure and only incidentally therapeutic. Mr. Ward does seem to be enjoying his brief respite, and as far as we or his wife are able to determine, he does not understand his prognosis. By carefully observing his fluid balance, we hope to be able to keep him free of heart failure and allow him to slip into uremic coma, before he realizes what has happened. We have very carefully considered the possibility of keeping him alive and definitely by means of dialysis. And, whereas this might be possible in a few selected cases, we have never been in a position to attempt it, and we do not think that we would be ready at this time, nor do we think Mr. Ward would be a candidate for such a drastic undertaking”. With great sadness we finally were able to convince Mrs. Ward to take her husband back to Spokane, where he died on March 6, 1960.
This experience caused Dr. Scribner to awaken in the middle of a mid-February night with the idea of the arteriovenous shunt that he subsequently developed with Wayne Quinton and Dave Dillard. The shunt (Fig. 1.3) consisted of Teflon tubing inserted into the radial artery and forearm vein that can be connected to the hemodialysis machine [7]. When not in use, the shunt was connected by a bypass loop on a metal arm plate secured to the patient’s forearm, thus eliminating the need for anticoagulation between treatments [7]. The use of Teflon tubing was important because the experience with Teflon tubing in cardiac surgery demonstrated that the material was nonreactive and the blood did not clot off easily in this type of tubing [2]. In 1960 there was no FDA or device regulation; thus the shunt was implanted and used. Scribner and Quinton presented the shunt during the annual meeting of the American Society for Artificial Internal Organs in Chicago [7, 8]. Several attendees took away the materials to place in patients but had problems with the shunt. This was attributed to lack of surgical expertise [2]. Dillard would spend between 1 and 3 hours carefully inserting the cannulas, and success of the shunt was attributed to his meticulous surgical technique [2].
Fig. 1.3
The Quinton-Scribner arteriovenous shunt in 1960. Top panel: Teflon tubing cannulas inserted into the radial artery and a forearm vein with the bypass loop and the metal arm. Bottom panel: the bypass loop is removed when placing the patient on hemodialysis, and the free blood flow was controlled using a blood pressure cuff while connecting to the dialysis machine (Courtesy of Northwest Kidney Centers, Seattle, WA)
The original Teflon shunt lasted for a few weeks or months, and the original patients including some with acute renal failure required several shunts in the upper and lower extremities. To increase cannula flexibility and longevity, Quinton added a silicone rubber segment, creating the so-called Silastic-Teflon bypass cannula where the tapered Teflon tips were inserted into the artery and vein and a Silastic tube made the exit through the skin (Fig. 1.4) [6]. Despite these advances, the shunts were useful only for a few months before failing. Complications included cellulitis, skin necrosis, sepsis, pulmonary emboli, shunt dislodgement or cannula extrusion, vessel stenosis, hemorrhage, and thrombosis. The mean half-life of the shunt was reported to be 6 months [9]. Despite these complications, the shunt was the decisive breakthrough that made maintenance hemodialysis possible [3].
Fig. 1.4
The original Teflon Quinton-Scribner arteriovenous shunt as first designed in 1960 (top panel) and the developmental progression of the shunts from 1960–1967 (bottom panel, left to right) and the addition of the silicone rubber segment, creating the Silastic-Teflon bypass cannula with tapered Teflon tips that were inserted into the artery and vein and the Silastic tube to exit through the skin (shunts photographed at the Northwest Kidney Centers’ Dialysis Museum, Seattle, WA)
During these early times of hemodialysis access, candidates for maintenance hemodialysis were carefully selected, and given the limited resources, many were turned down creating national headlines [10]. The history of hemodialysis is closely intertwined with the birth of bioethics, and this period of evolution in medical practice is detailed by the firsthand account of Dr. Thomas R. McCormick, Professor of Bioethics and Humanities at the University of Washington School of Medicine, in Chap. 8.
In 1973, T.J. Buselmeier and colleagues (Minneapolis, USA) developed a modification of the Scribner AV shunt. The Buselmeier shunt is a compact U-shaped Silastic prosthetic AV shunt with either one or two Teflon plugged outlets which communicated to the outside of the body. The U-shaped portion could be totally or partially implanted subcutaneously (Fig. 1.5) [11]. This shunt was designed to address some limitations of the Scribner shunt, namely, the long tubing that was prone to dislodgment and had high resistance to blood flow, and to limit the vascular intimal trauma that is the result of transmitted vessel tip movement. The Buselmeier shunt gained some acceptance during the following years, especially for pediatric hemodialysis patients [3].
Fig. 1.5
A schematic of the U-shaped Silastic prosthetic Buselmeier arteriovenous shunt used in the 1970s with two Teflon plugged outlets that communicated to the outside of the body. The U-shaped portion could be totally or partially implanted subcutaneously
The Repeated Venipuncture Technique in Surgically Created Subcutaneous Arteriovenous Fistula
Vascular access remained the Achilles heel of chronic hemodialysis, James E. Cimino (New York, USA) observed. The external Teflon-Silastic AV shunt (also called the Quinton-Scribner shunt) was associated with infection and thrombosis, and the alternative of repeated direct puncture of arteries and veins damaged these conduits every time the patient was connected to the dialysis machine. A patient could receive only a few treatments before all available access sites were utilized [12].
In 1961, Cimino, a nephrologist, and Michael J. Brescia (New York, USA) described a “simple venipuncture for hemodialysis” based on the experience of Cimino when he worked part time as a student at the Bellevue Transfusion Center in New York [13]. After infiltration of the overlying skin with 1 % procaine, the most accessible forearm vein was punctured with a needle. Needles varied in size from 16 to 12 gauge. Patency of the vein and adequate blood supply were assured by the application of tourniquet pressure with a sphygmomanometer. A blood flow in the range of 150 and 410 ml/min was obtained using this technique if the patient was fluid overloaded, but this was not sustainable in hypovolemic patients.
Cimino also noted that arteriovenous fistulas (AVFs) caused by trauma in Korean War veterans did not have significant effects on their health. Additionally, experience with surgically created fistulas was not new. During the 1930s, surgically created fistulas were placed at the Mayo Clinic in children with polio whose legs were paralyzed and not growing in order to promote collateral circulation. Cimino began to wonder if they could take advantage of the rapid blood flow and accompanying venous distention that occurred in the presence of a surgically created AVF despite the risk of developing heart failure as a long-term consequence. Dr. Cimino remarks that “We were bold in using a procedure that had always been considered physiologically abnormal, but without adequate vascular access our patients were doomed” [12].
On February 19, 1965, Drs. Brescia, Cimino, and Appel (surgeon) created the first autogenous arteriovenous fistula [14]. Dr. Appel performed a side-to-side anastomosis between the radial artery and the cephalic vein at the wrist using a 3–5 mm arteriotomy and venotomy in the corresponding lateral surfaces of the artery and the vein using arterial silk in continuous fashion for the anastomosis [14]. The fistula could then be accessed for dialysis by venipuncture. The first AV fistula dialysis attempt failed. Later, they realized it had failed for the same reason the original vein-to-vein technique had failed. “The patient had been prepared so diligently before the procedure that we removed too much fluid,” Cimino says. “His blood pressure was inadequate for keeping blood flowing through the newly created fistula.” After a period of trial and error, Cimino and his team were able to maintain adequate blood flow by using carefully placed tourniquets. They also found that despite their fears of inducing congestive heart failure from the fistula creation, patients’ cardiac function remained stable or improved following the creation of a fistula. By 1966, an additional 14 operations followed. He presented the result of his work at the Congress of the American Society for Artificial Internal Organs. Twelve of the 14 AVFs functioned without complications, two never worked (in the first patient, the anastomosis “was made too small”) [14]. To his surprise, the audience reacted with complete indifference [12] though over time this changed; Dr. Scribner from Seattle was the first nephrologist to refer one of his patients to New York for the creation of an AVF [15].
The evolution of the hemodialysis access continued when M. Sperling (Würzburg, Germany) reported the successful creation of an end-to-end anastomosis between the radial artery and the cephalic antebrachial vein in the forearm of 15 patients using a stapler in 1967 [16]. The creation of the end-to-end anastomosis was technically challenging and the diameters of the artery and vein were different. Thus this type of AVF was abandoned.
In 1968, Lars Rohl (Heidelberg, Germany) published the results of 30 cases where he used an end-to-side cephalic vein to radial artery anastomosis [17].After completion of the anastomosis, the radial artery was ligated distal to the anastomosis, resulting in a functional end-to-end anastomosis. With this technique, an antebrachial cephalic vein located at a more lateral position in the forearm, thus not suitable for a side-to-side anastomosis, could be used successfully. Later on, the ligation of the radial artery distal to the anastomosis was used in patients with impending signs of peripheral ischemia [17].
Alternatives to the wrist AVF were being explored during the same time period. In 1969 W.D. Brittinger (Mannheim, Germany) published his case series of 17 patients who underwent successful “Shuntless hemodialysis by means of puncture of the subcutaneously fixed superficial femoral artery for chronic hemodialysis” [18]. Following a femoral arteriogram to exclude arterial anomalies or disease, the superficial femoral artery was exposed by mobilizing the sartorius muscle which was then transected, passed underneath the exposed artery, and joined again. The fascia lata was closed, ensuring that proximal and distal openings of the fascia were sufficiently large to prevent compression of the artery [3].
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