|Year : 2019 | Volume
| Issue : 2 | Page : 127-128
A tribute to the inventor of arteriovenous fistula for hemodialysis: James E Cimino
Devender Singh, C Harita
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana, India
|Date of Web Publication||6-Jun-2019|
Dr. Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh D, Harita C. A tribute to the inventor of arteriovenous fistula for hemodialysis: James E Cimino. Indian J Vasc Endovasc Surg 2019;6:127-8
Vascular access is the lifeline of a hemodialysis patient. The evolution of vascular access has become a long way since the days of Scribner Shunt. Currently, arteriovenous fistula (AVF) and AV graft have been recognized as the permanent accesses for a dialysis patient. However, the evolution of technique of AVF was the sheer hard work and dedication of Mr. James E Cimino and his team which still continues to be the best modality of vascular access for hemodialysis throughout the world in the present era. For his contribution in the form of AVF for hemodialysis in the end-stage renal disease, he was awarded the prestigious 2009 Belding H. Scribner Award in the field of nephrology. We dedicate this historical vignette column for this great inventor, Mr. James E Cimino, who has made a huge impact in the practice of vascular surgeon's fraternity [Figure 1].
Dr. Cimino was born as Giacomo Cimino in 1928 in Bronx, New York. After finishing a residency in Internal Medicine in Buffalo and completing a stint as chief of medical services at Orlando Air Force Base Hospital, he wanted to move back to the Bronx, where he was raised. Dr. Cimino did not set out to become a hemodialysis pioneer; in fact, he was planning a career in pulmonary physiology. At 32, he was married and had three young children, and his father had just died. Hence, when the Bronx Veterans Administration Hospital offered him a job setting up a dialysis unit, he was tempted.
Although the Bronx VA hospital planned to use the dialysis machine to treat patients with acute renal failure and poisoning, Dr. Cimino agreed to take the job only on the condition that he is allowed to establish a chronic dialysis program. The Bronx VA hospital agreed, and Dr. Cimino and a colleague, Ruben Aboody, a technologist, began dialyzing patients at the bedside, then in a partitioned area in the corridor of the third-floor medical unit using a Kolff twin-coil artificial kidney. Dr. Cimino and Mr. Aboody dialyzed their first chronic renal failure patient in December 1960, gaining vascular access to the man's circulatory system by repeatedly inserting cannulae into his blood vessels. Unfortunately, the patient survived only a few days.
During this time, Dr. Belding Scribner, from Seattle, Washington, devised a Teflon catheter that connected a peripheral artery to a vein by way of a bridge. Although it was an improvement over other external cannulae devices, the external shunt or “Scribner Shunt” was prone to infection, clotting, and displacement leading to potentially fatal blood loss. Dr. Cimino and his team struggled with these frequent external shunt complications with their dialysis patients on a daily basis. The external shunts were also difficult for patients to tolerate psychologically. Those who lost one felt that their “lifelines” had been cut off and often became severely depressed. Moreover, a failed av shunt required patients to be readmitted and to undergo a painful, expensive recannulation procedure.
While pondering a possible solution to these problems, Dr. Cimino recalled his days working as a phlebotomist at the Bellevue Hospital blood bank during medical school. “The rapid blood flows we obtained from a needle connected to a Vacutainer –a vacuum bottle –had left an impression on me, and I thought, 'Why do not we take these veterans, who have big, bulging veins, and put the needles in those veins?'”
In 1961, Dr. Brescia joined Dr. Cimino and Mr. Aboody as a 3rd year resident [Figure 2]. They tried this vein-to-vein dialysis approach in several patients. While the team had some modest success with this method, the 250–300 cc/min blood flows necessary for optimal dialysis could be sustained only when patients were either overhydrated or in congestive heart failure. The technique was reported in the New England Journal of Medicine in 1962. Dr. Cimino began to wonder whether the vein-to-vein technique could be salvaged if he and his colleagues could take advantage of the rapid blood flow and accompanying venous distention that occurred in the presence of a surgically created AVF.
|Figure 2: The inventors: Kenneth C Apell, James E Cimino, Michael Brescia|
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He knew that some of the earliest surgical fistulae had been created in the 1930s at the Mayo Clinic. Doctors were trying to promote collateral circulation in children with polio whose legs were paralyzed and not growing. Doctors thought that if they could get adequate blood flow to the limbs before the epiphyses closed, maybe they could get the children's legs to grow. He also recollected that Korean War veterans with traumatic AVFs not only tolerated large AVFs without apparent cardiac complications but also were “easy hits” when drawing blood. Furthermore, patients tolerated repeated needle punctures without clotting or sclerosing.
When Dr. Cimino discussed the idea of creating AVFs for hemodialysis with his colleagues, they were cautiously enthusiastic. The Cimino team's first AVF dialysis attempt failed. Later, they realized it had failed for the same reason the original vein-to-vein technique had failed. They removed too much of fluid a day before the procedure leading to low blood pressure which was inadequate for keeping blood flowing through the newly created fistula.
After a period of trial and error, Dr. Cimino and his team figured out how to maintain adequate blood flow using carefully placed tourniquets. They also found that despite their fears, patients' heart functions either remained stable or improved following the creation of a fistula. Soon, most Scribner shunts were replaced with Cimino-Brescia fistulas.
By April 1966, Dr. Cimino had enough experience with the AVF needle technique to present the result of his work with 14 patients at the XII Congress of the American Society for Artificial Internal Organs. To his surprise, the audience reacted with complete indifference initially but later on slowly acceptance started across the globe. The AVF discovery revolutionized the hemodialysis field and was widely accepted, especially in Europe, following Dr. Cimino's guest lecture tour of European countries in 1968. Today, up to 90% of dialysis patients in some European countries use the AVF as the primary access, in contrast to <60% in the United States. Numerous studies have proven that the AVF has a lower incidence of infection, less clotting and thrombosis, fewer hospitalizations, and significantly less cost.
For the past several years, the Centers for Medicare and Medicaid Services has urged dialysis centers across the United States to adopt the Cimino fistula as the procedure of choice for end-stage kidney disease patients. “Fistula First” campaigns are promoted all over the world as the first line of treatment for a vascular access.
James Cimino died quietly at home on February 11, 2010. Dr. Cimino is best known for his conception of the AVF, which was originally published in the N Engl J Med in 1966, along with coauthors Dr. Michael Brescia, Dr. Kenneth Appel, and Dr. Baruch Hurwich. Today, the AVF is widely accepted throughout the world as the vascular access procedure of choice and majority of vascular surgeons' work is the result of this invention. This is truly a great milestone in the history of invention for managing end-stage renal diseases.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ronco C, Blagg CR. James E. Cimino, M.D.: Recipient of the 2008 international society for hemodialysis Belding Scribner trailblazer award. Hemodial Int 2008;12 Suppl 1:S66-7.
Maggiore Q. The fiftieth anniversary of the arteriovenous shunt for chronic hemodialysis. G Ital Nefrol 2010;27:557-8.
Rigolosi RS. A tribute to a dialysis pioneer: James E. Cimino, MD. Hemodial Int 2010;14:154-5.
[Figure 1], [Figure 2]