History of vascular access Hemodialysis is one of the main hands of modern alternative treatment for kidney disease. The history of dialysis therapy goes back almost to the beginning of human civilization, but it was not until the twentieth century that hemodialysis entered a new era. Along with the development of hemodialysis, vascular access has undergone a long process of development. Initially, blood was collected with a syringe and injected into a dialyzer, and then injected back into the patient’s blood vessels with a syringe after dialysis, with all the problems that this entailed. For more than 20 years after 1940, each dialysis session required cutting off an artery, inserting a glass or metal tube to establish vascular access, removing the cannula at the end of treatment, then ligating the vessel and reinserting the cannula at the next dialysis session.
Since the human body has a limited number of blood vessels available, such repeated ligation of blood vessels soon forced the interruption of dialysis due to blood vessel depletion. Therefore, at that time, dialysis was limited to resuscitation of acute renal failure and poisoning, and the success rate of resuscitation was very low due to the backwardness of dialysis technology. Early dialysis scholars such as Alwall and Teschan tried to improve vascular access, but were unsuccessful due to blood clotting and catheter material problems.
In 1949, Alwall and Bergsten et al. used a glass tube to connect the carotid artery to the internal jugular vein of an anuric rabbit for dialysis treatment, but the treatment lasted only one week due to coagulation problems. In 1953, Belding Scribner at the University of Washington became interested in dialysis at the urging of John Merrill, initially concerned with the removal of water and the effect of dialysis on electrolyte balance, before recognizing the importance of establishing continuous vascular access. In the following years, he and his assistant Wayne Quinton studied and evaluated many materials and finally decided that polytetrafluoroethylene (PTFE) was the most suitable material, with the trade name Teflon, which prevented eggs from bonding to the pan, thus suggesting that the material might also prevent blood bonding. The test results confirmed their idea.
On March 9, 1960, Quinton, ScribneDilland, and others first used two Teflon tubes inserted into the adjacent arteriovenous vessels of the arm of a dialysis patient named Clyde Shields, and connected them in vitro for repeated use. During the interdialysis period, clotting was largely prevented because of the continuous flow of blood through the catheter. The success of this procedure enabled patients with chronic renal failure to undergo intermittent hemodialysis for a longer period of time, ushering in a new era of hemodialysis treatment and was the first milestone in the history of vascular access. This vascular access is called arteriovenous fistula, also known as Quinton-Scribner bypass or arteriovenous bypass (
arterio-venous shunt). Initially, the Teflon catheter was a stiff material that often irritated the intima when the patient’s arm was moved, causing vascular damage and thrombosis. Silicone had better flexibility, but silicone manufacturers at the time did not produce silicone catheters for blood delivery. In 1961, this type of fistula was introduced into the clinic, and the shape of the fistula was also improved, with the subcutaneous portion of the catheter inlaid with silicone wings to facilitate suturing and fixation of the fistula. The shape of the fistula was also improved with the addition of silicone wings to the subcutaneous portion of the catheter to facilitate suture fixation of the fistula.
The use of silicone, a new biocompatible polymer that is flexible and elastic, extended the life of the fistula by 5 to 10 times, allowing many patients to undergo long-term maintenance hemodialysis. The first patient in history to use a fistula for dialysis survived for 11 years before dying of a myocardial infarction. At that time, for various reasons, the average lifespan of an external fistula was not very long, typically 7 to 10 months. Whenever a fistula lost function due to occlusion, infection, or other reasons, the arteries had to be ligated and the fistula recreated, and after several years of this repeated procedure, the superficial blood vessels throughout the body were eventually depleted and eventually faced interruption of dialysis again.
In the late 1960s, many scholars tried to improve the fistula. Buselmeier et al. used two blood cells in the extracutaneous portion of the fistula to avoid disconnection and connection of the fistula during dialysis and further suggested that the device could be implanted subcutaneously, exposing only two blood cells outside the skin, thus prolonging the life of the fistula. Thomas had used polyester sheets sewn to the margins of the superficial femoral artery to allow immediate use of the fistula and to provide greater blood flow, but infection remained difficult to resolve. The later Allen-Brown fistula, which was secured to the end of the silicone tube with a polyester sleeve and sutured to the end of the vessel, had some success.
Despite all the improvements made to the external fistula, its lifespan is only 6 to 12 months. In addition, there is a high incidence of complications associated with it such as infection, thrombosis and bleeding. Ischemia of the extremity often occurs due to ligation of the vessels; Hoeltzenbein and Belzer attempted to create external fistulas using the deep femoral artery and the saphenous vein, and Kaufmann described the creation of external fistulas using the superior abdominal wall artery and vein. However, none of them fundamentally addressed the issue of complications and longevity of external fistulae. It is undeniable that the Quiton-Scribner fistula made an outstanding contribution to the development of vascular access for hemodialysis in the years preceding and even in the following two decades, and it is not an exaggeration to call it the first milestone.
The invention of the arteriovenous fistula Although the arteriovenous fistula made possible the maintenance dialysis treatment of patients with chronic renal failure, its serious complications such as infections, thrombosis, and bleeding, as well as its short lifespan, were difficult to overcome.
Efforts continued to find more optimal vascular access.JamesCimino, MD, worked at the Bellevue Blood Bank in New York during his fourth year of medical school, and Cimino gained experience in blood collection techniques, which he applied to hemodialysis.In 1962, he and Michael Brescia described an arteriovenous puncture technique using a 17-gauge puncturing a vein with a 17-gauge needle and then tying a sphygmomanometer cuff around its proximal limb, which resulted in a greater blood flow. With these experiences, Cimino thought of the possibility of an internal fistula, and he and fellow surgeon Kenneth Appel created the first arteriovenous endovascular fistula by anastomosing the patient’s forearm cephalic vein to the radial artery. This technique was then perfected with the help of Brescia, Aboody and Hurwide.
et al. reported the use of radial artery-cephalic endovascular fistula in 13 dialysis patients with chronic renal insufficiency, who started dialysis treatment the day after the procedure with the aid of a tourniquet to dilate the cephalic vein. They also found that as time went on, the cephalic vein became more dilated and the wall thickened, making dialysis puncture easier. Their findings were published in the New England Journal of Medicine in 1966.
The advent of this technique opened a new chapter in hemodialysis treatment and was the second milestone in the history of vascular access. This endovascular fistula is called an arteriovenous fistula (AVF) or Brescia-Cimino endovascular fistula.
The AVF is a direct subcutaneous anastomosis of the artery and vein without any exposed skin, reducing the chance of infection.
The incidence of thrombosis is low, and there is no need to ligate the vessel after each puncture, making it the safest and longest-used vascular access for maintenance dialysis patients. To date, the Brescia-Cimino endovascular fistula is still the irreplaceable permanent vascular access.
After the 1960s, arteriovenous endovascular fistulas became popular worldwide. The procedure is performed under local anesthesia and is ready to go home the same day. Initially, the anastomosis was a lateral arteriovenous anastomosis, and later end-to-end and end-to-side anastomoses were introduced. At that time, puncture dialysis was started immediately after surgery, but it was later found that an arteriovenous endovascular fistula should be given 4-6 weeks of maturation to allow adequate dilatation and arterialization of the anastomosed vein. In addition, patients with chronic renal failure who are rapidly progressing and will require dialysis should be prepared for the creation of an endovascular fistula in a timely manner, with attention to
Many studies in the 1970s and 1980s looked at the opening rate of arteriovenous endovascular fistulas and noted that there were two categories of endovascular failure: early and distant. The early failure rate is around 5-12%, which is mostly related to rough surgical operation, slender vessels and inadequate dilation, and these causes of endovascular failure mostly require rebuilding the endovascular fistula. Late failure is mostly related to atherosclerosis and intravenous hypertrophy at the anastomosis, in addition to post-dialysis hypotension and aneurysm formation.
Graft endovascular fistula Although arteriovenous endovascular fistulas are currently the most desirable permanent vascular access, endovascular fistuloplasty is not possible in every patient. In those patients with superficial arteriovenous lesions or severe damage or even absence, vascular replacement has to be considered. Bridging the arteriovenous vessels with a replacement vessel became the next topic of research. The search began in the 1970s, and by the 1980s a new era of research in this area was underway. The material for the graft needed to be easily available and inexpensive, with good biocompatibility, low thrombosis rate, and ability to tolerate repeated punctures.
et al. successfully performed endovascular graft angioplasty using the saphenous vein and observed the first patients for 13 months, concluding that the human saphenous vein could be used as a graft vessel to create an endovascular arteriovenous fistula. However, studies have found that saphenous vein graft endovascular fistulae are less effective in tolerating repeated punctures and are prone to early occlusion.
In 1976, Rosenberg et al. first treated a bovine carotid artery with figmentase, removed the muscle and elastic layer, and fixed the remaining collagen vessels by de-antigenizing them in a dialdehyde starch solution, and then created a graft endovascular fistula. Many subsequent studies found that although this type of endovascular fistula was easy to perform and had good hemostasis after puncture, the long-term patency rate was low and biocompatibility was poor.
Meanwhile, the use of fresh allogeneic vessels, frozen vessels and cadaveric vessels as grafting materials has been thought of, but all of them were taken due to poor compatibility.
However, their use was limited due to poor compatibility and difficulty in obtaining materials.
The advent of artificial vessels in the 1980s largely improved the situation of endovascular fistulae in grafts. Artificial vascular materials are made of fabric or synthetic polymers. In the early days, polyester (dacron) was the most used vascular material, using polyester yarns woven into vascular substitutes. In 1978, Campbell et al. reported the clinical application of polytetrafluoroethylene (PTFE) artificial blood vessels. PTFE expands when heated and becomes a regular, porous structure with a micro-net of fine eyes, also known as expanded PTFE (e-PTFE). Electron microscopy reveals that these vessels have a large number of nodules and fibers, a structure that allows tissue to grow into the vessel wall to increase its stability. Many studies in the 1980s found that the 2-year patency rate of PTFE endovascular fistulas was 61-91%.
PTFE vessels have unparalleled advantages over other vascular materials, such as easy access, good biocompatibility, easy puncture, and resistance to both infection and thrombosis. Therefore, PTFE vessels are currently the most widely used graft vascular material.
Development of central venous cannulation: In 1953, Seldinger et al. used a method of percutaneous catheter insertion through a guidewire to successfully perform arteriography in a patient, which later became known as the Seldinger technique and has been used ever since. 1961, Stanley Shaldon, then a hepatologist, used the The Seldinger technique was used by Stanley Shaldon, then a hepatologist, to insert a catheter into the femoral artery and vein for hemodialysis treatment, and the catheter was removed after dialysis. This pioneered the use of central venous catheters in hemodialysis, which became known collectively as the Shaldon catheter.
In 1963, Shaldon et al. attempted to retain a femoral static catheter for maintenance hemodialysis for a long time, using heparin drips to prevent thrombosis, but there were many complications with this measure. The following year, Tomoseck et al. modified femoral arteriovenous cannulation by inserting two catheters in the ipsilateral femoral vein as vascular access, thus greatly reducing complications such as bleeding and leaving them in place for a longer period of time. Due to the high incidence of pulmonary embolism caused by catheter placement at that time, Shaldon et al. advocated that femoral vein catheters should no longer be used as permanent vascular access, but only as temporary vascular access. However, endovascular fistulas were not available at that time, so they continued to use external arteriovenous fistulas as maintenance vascular access. In the years since then, the
Smith, Matalon, Nidus, and others performed a lot of practice and research on femoral vein cannulation and made a series of modifications that largely improved the safety and longevity of the catheter.
The subclavian vein cannulation technique was done by Uldall in 1963 using the Seldinger technique, so the subclavian vein catheter was also called the Uldall catheter, but it was not intended for hemodialysis at that time. In the 1970s, the subclavian vein cannulation technique was increasingly used in clinical practice, and it was found that the infection rate of subclavian vein cannulation was lower than that of femoral vein cannulation, and that patients could take the catheter home with them without the need for prolonged hospitalization. in 1979, Uldall et al. improved the catheter so that the retention time of the catheter The retention time of the catheter was extended to an average of 21 days. In the 1980s, as catheter materials improved and dialysis modalities evolved, subclavian vein catheters became more widely used and were left in place for significantly longer periods of time, with some dialysis centers even using them as long-term vascular access for patients unable to establish endovascular fistulas.
Subclavian vein cannulation is technically difficult and requires extensive practical experience of the operator.
It also has relatively more complications, such as venous stenosis, hemopneumothorax, and difficulty in stopping bleeding after injury to the artery. The internal jugular vein cannulation is simpler, safer and has a high success rate, which has been observed by Lawin and Bambauer et al. Currently, the internal jugular vein has become the preferred central venous cannulation route for hemodialysis.
The emergence of central venous cannula as a temporary vascular access and arteriovenous endovascular fistula as a permanent vascular access made the defects of external arteriovenous fistula more prominent, and after the 1980s, external arteriovenous fistula has gradually retired from the stage of history.
Semi-permanent vascular access – central venous catheters with cuffs (Cuff)
Percutaneous central venous cannulae were initially used primarily for temporary vascular access and soon replaced arteriovenous fistulas.
It was one of the most important vascular accesses for short-term dialysis, but complications such as infection limited its long-term use. In the late 1980s, silicone dialysis catheters with polyester sleeves were utilized as permanent vascular access. The initial placement sites were the internal jugular and subclavian veins, but it was later found that the subclavian vein placement caused a significant increase in venous stenosis and thrombosis, so the right internal jugular vein is now the preferred site for cannulation. The central venous catheter with Cuff significantly extends the life of the catheter, but ultimately it cannot be used for a long time, with an average life of only 18-24 months.
Therefore, we call it semi-permanent vascular access.
Therefore, we call it semi-permanent vascular access. For those patients who are estimated to have a long maturation time for endovascular fistula, this catheter can be used as a transition to vascular access; for those patients who really cannot establish endovascular fistula and need hemodialysis, we can only try to make this catheter last as long as possible, in order to replace permanent vascular access. However, the central venous dialysis catheter with Cuff still has a high rate of infection, thrombosis, and inadequate blood flow, and a repeat circulation rate of 4-12%.
The rate of repeat circulation is also as high as 4-12%. Although some improvements in catheter materials and shapes have been made, the results have not been satisfactory.
Needle-free Dialysis Access
Autologous arteriovenous endovascular fistulas or graft endovascular fistulas require venous puncture during dialysis and are inevitably associated with pain or injury. In the 1980s, a new type of vascular access was developed, called Hemasite and Bentley Dia AP access, which combines the features of a graft endovascular fistula with those of an arteriovenous fistula.
The NNAVG has an inverted “T” cylindrical shape with a horizontal branch that bridges to the PTFE graft and a longitudinal branch that penetrates the skin to connect to the dialysis line and is closed with a silicone cap when not on dialysis. Since the connector of Dia TAP device is exposed outside the skin, the incidence of local and systemic infection is high.
The incidence of local and systemic infections is high, and sometimes the device must be removed because it is difficult to control with antibiotics. In addition, thrombosis is common. It has been observed that the patency rate of the device is 60% at 1 year and 20% at 4 years. Furthermore, after 1 year of use, damage often occurs at the connection between the PTFE vessel and the device, which can cause severe bleeding. Due to the serious complications and high cost of the device, Dia TAP
vascular access has not been widely available.
In recent years, there is a completely subcutaneous hemodialysis access (subcutaneous devices) used in the clinic, compared with the Cuff catheter dialysis effect is good, the complication rate is low, the more widely used are LifeSite
and Dialock hemodialysis access systems. Since this type of access requires repeated punctures at skin sites and also requires heparin to seal the tubing, infection and thrombosis are still two major problems.