"The American Surgeon" Recognizes Kenneth Appell's Invention of the AV Fistula

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As recounted in this Web site's very first post, on August 2, 2008, Dr. Appell was contacted in the summer of 2004 by José Ramón Polo, head of vascular surgery at Marañón Hospital in Madrid, Spain. Dr. Polo's conviction that credit for the AVF had been hijacked was so strong that he felt driven to help set the historical record straight, and toward that end was working on an article he hoped to publish in a widely-circulated English-language medical journal. The resulting article was finally published in the February 2007 issue of The American Surgeon (Vol. 72, No. 2).

It must be noted that due to an error in transcription, the dates given in this article for the first and second fistulas are incorrect, and unfortunately this mistake was not caught in proofing. Instead of the date of February 1965 for the first attempted AVF and March 1965 for the second, the first attempt in fact occurred in February 1963 and the second in March 1964.

Following is the text of Ramón Polo's article:

Historical Vignette: Kenneth Charles Appell, M.D.: The Surgeon Who Performed the First Radiocephalic Fistulas for Hemodialysis

José R. Polo, M.D., Ph.D.
Department of Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain

Radiocephalic fistula for hemodialysis is the most effective vascular access since it was developed at the Bronx Veteran's Administration Hospital in New York by Kenneth Charles Appell in February 1965. The first fourteen cases were published in a classical paper (N Engl J Med 1966; 275:1089-1092). Some aspects of the biography of Dr. Appell, together with the history of the development of radiocephalic fistula are described in this historical communication. Dr. Appell, age 82, is currently living in New York's Hudson Valley.

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Very few surgical operations are commonly associated with the name of the surgeon who designed them (the Nissen funduplication, the Halstead mastectomy, the Whipple pancreatoectomy, and so on). Generally speaking, all these operations remained practically unchanged with time and continue to be very successful. The purpose of this brief paper is to remind the medical community of the surgeon who designed and performed the first radiocephalic fistulas for dialysis, Kenneth Charles Appell, whose name was unfairly forgotten and never associated with the surgical technique that he designed in the 1960s.

Kenneth Charles Appell was born in 1923 and attended Manhattan College in New York City. He enlisted in the U.S. Navy in 1942, serving in the South Pacific during the Second World War. After coming back from the Pacific, he completed his college education and then matriculated at Georgetown University Medical School in Washington, D.C.

Afterward, he performed his training in general surgery at Saint Vincent's Hospital in New York City and the Veteran's Administration Hospital (V.A.) in Brooklyn, New York. He was mainly interested in oncologic and vascular surgery. He performed his first repair of an aortic aneurysm in 1957.

Hemodialysis was performed at the Bronx V.A. Hospital in 1960 under the care of internists Michael J. Brescia, M.D., and James E. Cimino, M.D. Dr. Appell performed the Scribner shunts that were then used as vascular access for dialysis. Various alternatives were tried to avoid the many complications associated with the external shunts, including the interposition of a small 4-mm-diameter Dacron segment that was usually subject to thrombosis. Direct anastomosis of the vessels was avoided because traumatic arteriovenous fistulas were often associated with cardiac failure. In 1961, Dr. Appell became aware of a paper from the Mayo Clinic describing a 10-year study in which arteriovenous fistulas were used to increase bone growth in children. Dr. Appell was convinced that a small radiocephalic fistula would be well tolerated.

The first fistula was performed in February 1965. It thrombosed, probably because of the small diameter of the vein used. The second fistula was performed in March 1965, and the patient was dialyzed for a long time by puncturing the dilated vein without any problem. One hundred forty-three procedures performed at the Bronx V.A. Hospital were presented by Dr. Appell in 1989 at the first meeting on Vascular Access for Hemodialysis (Phoenix, Arizona) organized by Ohio University. The main technical aspects currently used for the procedure were then described: use of microsurgical instruments and magnifying lenses, and fine suture. The results of the first 14 patients with radiocephalic fistulas created for hemodialysis were published in a classic paper in the New England Journal of Medicine in 1966. Since then, the procedure was generally referred to as the Brescia-Cimino fistula.

Dr. Appell left academic surgery in 1970 and continued performing general surgery in New York's Hudson Valley until he retired. Dr. Appell, currently 82 years old, continues to live in that area with his charming wife, Marcella. I believe that all surgeons, nephrologists, nurses involved in hemodialysis, and dialysis patients are indebted to Dr. Appell for the development of this simple and successful operation.

Kenneth Appell's 2007 Speech About His Invention of the AV fistula

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On November 14, 2007, Dr. Appell was recognized for his historic development of the AV fistula at the New York City meeting of the Vascular Access Society of the Americas at the Veith Symposium. In addition to being presented with an award, he was invited to give an address describing the circumstances surrounding the AVF's invention, and thoughts and observations regarding the procedure. Following is the text of his presentation:

The Concept of an A-V Fistula for Vascular Access

I would like to present to you some of the history of hemodialysis and vascular access surgery as I lived it. In 1960 the administration at the Bronx Veterans Administration Hospital decided to establish a hemodialysis clinic. A clinic in those days was an institution that did one dialysis per week. In New York City there were four such clinics: BVAH (where I was associated), Mount Sinai, Bellevue and DownState in Brooklyn.

Our dialysis machine at the BVAH was the Kolff twin coil and the team consisted of two internists, a surgeon, a lab technician and a nurse. The problem then, as it is now, was one of vascular access. The technique then employed was the use of the Scribner shunt. This shunt was developed at the University of Washington in Seattle by Quinton, Dillard and Scribner. Quinton was an engineer, Dillard a surgeon, and Scribner an internist.

The shunt in essence was a controlled AV fistula, controlled essentially by the diameter of the Teflon catheter and the connecting tubing. Such a controlled fistula is in contrast to a native AV fistula which is usually traumatic and involves large vessels. The literature at the time was replete with the adverse effects of native fistulas. They were to be avoided.

The Scribner shunt had many problems, including bleeding, infection, erosion, clotting, and the need for the patient to have a bulky dressing in order to maintain some sense of sterility.

In 1961, an article appeared in the Proceedings of the Mayo Clinic which described a ten-year study in which a group of children with a shortened limb (usually secondary to polio) were subjected to the construction of a native AV fistula in the hope that the increase in blood flow would cause a corresponding increase in limb growth. Their fistula was one half-inch in diameter and connected the superficial femoral artery with the deep femoral vein. A slight increase in heart size and heart rate and the typical murmur of an AV fistula developed in all of the children, but they appeared to tolerate these changes and these changes were reversible with closure of the fistula.

This was the first time I had found evidence in the literature which would correlate the effects of fistula size and vessels involved with the patient’s response. The consensus at the time was that all AV fistulas were to be avoided because of their adverse effects and difficulty to repair.

I reasoned that if such a large fistula involving major vessels, albeit in children, could be tolerated, would not a smaller fistula in smaller vessels be tolerated in adults.

This was my epiphany.

In February 1963 I attempted my first case. Vascular surgical instruments for this type of microsurgery were not available, so I went to the Department of Ophthalmology at BVAH and borrowed their equipment, including a loop magnifier. The first patient happened to be a very poor candidate for an AV fistula as he had very poor veins. I was, however, able to construct a side-to-side anastomosis between that small vein that crosses obliquely across the volar surface of the wrist and the radial artery. I estimated that the fistula was approximately two millimeters in diameter. I had hoped that with the increase in venous pressure additional veins would open up but this did not happen and it never does. This first case therefore was a failure as a means of vascular access but I was encouraged, because having never worked with vessels of this size before, I was able to construct a patent AV fistula.

My next case was in March 1963 and was a much better candidate. I was able to create a side-to-side radial-cephalic fistula which worked perfectly. With this success I gradually changed from Scribner shunts to peripheral AV fistulas.

My technique changed little over the years. The patient was prepped with alcohol and Betadine and the anesthesia employed was 2-percent Xylocine. A four-centimeter transverse incision was made over the anteria-lateral aspect of the wrist just proximal to the radial styloid. The subcutaneous tissue was not incised, as I felt this would offer some protection to the overlying skin and the underlying anastomosis. Disection then continued medially down to the antibrachial fascia, which was incised longitudinally. The artery was freed up over a distance that would allow easy displacement of the vessel from its bed without kinking. This latter consideration is most important in mobilizing both the artery and the vein. Vascular loops of 2-0 black silk were used to control the vessel. Disection then continued under the subcutaneous tissue at the level of the fascia to the cephalic vein located laterally in the subcutaneous tissue. The vein was likewise freed-up over a longer length than the artery but again avoiding any kinking or obstruction. At this point the patient was heparinized with 5,000 units of sodium heparin, and dilute heparin was subsequently used as an irrigating fluid. With both vessels controlled with tapes, they were brought together under the subcutaneous tissue. The tapes are used to both control position and to control blood flow; by increasing tension on the tapes, bleeding can be adequately controlled. I tried to avoid vascular clamps because I felt they were too traumatic, and besides they cluttered the field. An incision was then made with the tip of a No. 11 scalpel, and this was then enlarged to about five to six millimeters with a curved iris spring scissor. A side-to-side anastomosis was made in an over-and-over fashion with 6-0 or 7-0 silk (silk was the only available suture material at the time and it subsequently was replaced with Proline). With completion of the anastomosis, the opening should be about five millimeters. When mature, this would give a flow rate of 250 to 350 ccs per minute. The tapes are removed sequentially, first the venous side, then the distal artery, and finally the proximal artery.

A definite thrill should be palpable and venous distension may be observed. If a thrill is not present you must assume an error in technique and it should be corrected. In my experience no fistula has failed to function if a thrill was present. Careful inspection of all vessels to assure that there is no kinking or obstruction should be done. The skin was closed with interrupted nylon sutures.

Postoperatively heparin is not continued. The hand is elevated on a pillow until edema which usually occurs has subsided. Pressure bandages and elastic bandages are to be avoided.

A well constructed AV fistula can be used almost immediately, but it is better to allow a four- to six-week period for maturation to occur as this will make needling easier and give better flow.

The first ten years of access surgery at the BVAH involved 112 patients and 143 procedures. A total of 100 side-to- side and 43 end-to-side AV fistulas were constructed. One can expect a long life from a properly constructed and maintained AV fistula. For example, in 1965 Dr. Scribner sent me a patient in whom I was able to construct a peripheral fistula. In 1987, he presented that patient at a conference on vascular access in Phoenix, Arizona, and at that time the patient had had over 20 years of dialysis treatment with the same fistula. A life span of 20 to 30 years is not unheard of.

Every surgical procedure has its complications, and the peripheral AV fistula is no exception. Fortunately, they are not too common and are usually correctable without difficulty.

Aneurysms, both true and false, occur. The latter are usually the result of faulty needle technique. False aneurysms should be repaired, as they can obstruct venous drainage. True aneurysms occur at the A-V site and need not necessarily be repaired. I have never seen a peripheral aneurysm rupture. If they become unsightly or symptomatic, they should be excised and a new anastomosis constructed at a more proximal level.

Congestive heart failure is a rare complication. I preferred to treat this problem by exposing the fistula site and narrowing the stoma with well placed sutures.

The blue thumb or sore swollen hand syndrome is due to venous hypertension and should be treated by ligating any enlarged vein distal to the fistula. More frequently, however, venous hypertension is secondary to more proximal narrowing or obstruction. A brachial angiogram may be necessary to define the obstruction. Adequate bypass, e.g. venous graft or side-to-side venous anastomosis, may be necessary. Occasionally thrombectomy may be successful.

I did not encounter the “steel” phenomenon. Perhaps because the patients I encountered were younger than those you see today. I always preoperatively ascertained the competence of the ulnar artery flow by the Allen Test. I would not insert an AV fistula if it were felt that the ulnar artery was incapable of providing adequate peripheral circulation.

I would like to emphasize that the success of a vascular access program depends largely on the physician who first anticipates the subsequent need of his patient for dialysis. The venous pattern of the non-dominate arm (if available) should be protected absolutely from all attempts at bloodletting, I-Vs and I-V medication.

The concept of a peripheral AV fistula as a means for repeated access to the circulation is a concept that has established itself. It should be considered in any long-term therapy program requiring such circulatory access.

In conclusion, let me leave you with the logo of the hemodialysis unit at the University of Oklahoma -- namely, “Fistula First.”

Bronx V.A. Hospital Chief of Surgery Andrew James McElhinney Discusses Kenneth Appell's Invention of the A.V. Fistula

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Now semi-retired, Dr. McElhinney graciously granted an interview to this Web site on April 14, 2009 at his home in Pelham, New York, just north of the Bronx. The transcript of that interview follows.




“I’m Jim McElhinney, retired surgeon. I was Chief of Surgery at the Bronx V.A. from 1975 to 2003, and I first met Ken Appell when I was a resident, a surgical resident in the V.A., from '59 to '62 and through '63. And so I was there when he developed the arteriovenous fistula for patients on hemodialysis. Prior to that time, the patients who were in kidney failure and needed dialysis had to have their dialysis run through catheters put into the blood vessels in their arms or wherever to dialyze them. The Scribner shunt was the first shunt implanted which implanted catheters in the vessels. And then Dr. Appell conceived the idea of making an arteriovenous fistula -- an anasthemosis or connection between an artery and a vein in the wrist area. This enabled the blood supply to be easily accessed with a needle and then removed after the dialysis was performed.

As a result of that, the Bronx V.A. had the largest hemodialysis unit in the New York area -- because of the development of the AV fistula by Dr. Appell. He worked with Drs. Brescia and Cimino, the nephrologists, and it's often called the "Brescia-Cimino shunt." But it really should be called the "Appell shunt," because he was the one that manufactured it. He had been interested, before doing the shunt for dialysis, in perhaps using a fistula down in the foot area, ankle area to increase flow through the blood vessels that were being reconstructed for people who had inadequate blood supply to their legs. And so he was familiar with the concept of anasthemosing an artery and a vein together. He didn't pursue that any further, as far as I know, but then he went on and did many different things, excelled in many different areas of surgery, including vascular surgery. And I was there when he started the fistula, and after he left I took up the production of the AV fistulas and I had several people on my staff who later developed -- didn't develop but continued to work on the same principle that Dr. Appell had pioneered and developed.

Q: Great, and what was your understanding of the timeline? What was the nature of Dr. Appell's association with Drs. Cimino and Brescia, and how is it that it became confused subsequently as to who was responsible?

Well, they were the senior authors on the paper, so I think that's how it became known as the Brescia-Cimino shunt. In Europe, some of the surgeons told me, that in Europe it was called the "Bronx shunt" because it was developed at the Bronx VA. But I had always reminded people in different lectures that I gave around the country that it was Dr. Appell who really developed the shunt that made all of hemodialysis so much more practical and expanded it to so many people with kidney failure. He was recognized at several of the vascular meetings as the developer of the shunt -- or the fistula, I should call it, really. And it's just taken for granted today that unfortunately not many people realize that he was the one who was the developer of it.

Q: I'm curious as to when you first learned about the idea of the AV fistula, the idea and the actual success of it, and what you reaction was.

Well, that was when I was a surgical resident, first in general surgery and then in cardio-thoracic surgery. And I used to sometimes assist and other times just watch Dr. Appell -- because it's a miniature incision in the wrist, and you can't really have too many people working at the same time. But I used to watch to see how he was doing it and what the techniques were and what the problems were associated with the creation of the fistula. And so the people at the Bronx VA after Dr. Appell left continued on and also became very proficient in it -- as have people all around the world.

Unfortunately, some people look for a simple answer to the problem of kidney failure, and put in a synthetic graft in the arm or anyplace in the body to make an easier graft from the, say the wrist or even the upper arm, from an artery to a vein. The problem with using those synthetic grafts is that their life is quite limited and it then creates other problems. Even though it makes it simpler to do initially, the much better solution is the autogenous tissue of the AV fistula.

Q: So you would agree with the philosophy of "fistula first," with the native fistula, as opposed to the other alternatives that have been developed?

Absolutely, and also to persist in using the fistula, because sometimes it's very easy to just say, "Oh, we'll stick in a graft, and that's quicker and easier," but -- it's quicker and easier but it's not as good, and not as lasting, and it poses a lot of its own problems.

Q: Very good. One last question. Were you friendly with Dr. Appell at the time? Did you socialize at all? What did you think of him as a person?

Oh, he was a wonderful man. He was a young attending in surgery and I was a resident -- first chief resident in general surgery and then in cardio-thoracic surgery. And so we did work together as resident and attending on many cases, and he was an excellent surgeon -- all-around surgeon, not just in fistulas and vascular surgery but in all areas of surgery.

Q: Well, he always said it was a pleasure to work with you, so I thank you for your time.

Oh, you're quite welcome!"

AVF Inventor Kenneth Appell Discusses Fistula's Limitations

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Dr. Kenneth Appell remains engaged in current medical developments and thinking, and recently had an interesting exchange with Long Island, NY nephrologist Simon E. Prince, who industriously and informatively puts out The Nephrology Blog. This past February 25, Dr. Prince added the following post:

Vascular Access Controversies

The Renal Business Today website has an interesting 'roundtable' discussion on Vascular access today.

This follows the excellent thought-provoking recent videoblog of Dr Berns: AV Access and Fistula First? This is then followed by some excellent comments from the nephrology community.

I support Fistula First. But also, I believe an AVF is not always appropriate. I believe the rhetoric can be toned down a notch. Dialysis units are incentivized to have a higher %AVF, and it although it is undoubetdly usually the best option... it is not always the best option for each individual patient.

Some examples where Fistula First may not be best:

1) Potentially reversible disease. There are instances of acute renal failure which requires dialysis, but recovery is anticipated... or at least possible.

2) Poor life expectancy. Some of our patients have such terrible co-morbidities that AVFs are not the appropriate.

3) Short term use of dialysis/ ultrafiltration. Such as for someone with congestive heart failure who requires atypical treatments based upon complimenting medical therapy.

4) Terrible vascular anatomy. Sometimes it is not feasible to attempt an AVF... although, there are many talented Vascular surgeons who can usually succeed in even the most difficult cases.

5) Some patients show up at the hospitals with stage 5 CKD and need RRT and it is logistically difficult to arrange an AVF prior to discharge (these patients should have "Fistual Second")

In a perfect world, no one can argue fistula first... unfortunately, circumstances (especially within the patient population we deal with) are not always ideal.

Dr. Appell commented on March 2:

As the originator of the peripheral A-V fistula, I agree in general with your comments.

The peripheral A-V fistula is the best method for chronic vascular access. We can anticipate 10 to 20 to 30 years or more of use from an A-V fistula.

However, there are instances where an A-V fistula would not be indicated.

In patients with multiple or severe co-morbidity that may be life-threatening it would not be indicated. Other means are available for dialysis. After all, an A-V fistula requires an operative procedure.

The A-V fistula is designed for long-term use. Patients requiring short-term dialysis are best treated by central lines.

The question of closure of an A-V fistula following a successful kidney transplant would depend upon the particular patient. If the fistula is not unsightly we should consider keeping it as a backup. Fistulas are well tolerated and do not detract from the transplant.

In general, as in all good medicine, the therapy should be designed to fit the patient and not vice-versa.

Dr. Prince graciously responded that same afternoon:

Such a distinguished guest... I am honored, Dr. Appell. Thank you for your contribution to the field of Nephrology… as well as for taking the time to comment here.

AV Fistula Inventor Kenneth Appell Salutes Hemodyalisis Inventor Willem Kolff

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One of the great medical innovators of the past century died yesterday in Philadelphia, three days short of his 98th birthday. More recently known also as one of the designers of the artificial heart implanted in Dr. Barney Clark in 1982, Dr. Kolff was born in the Netherlands and began his attempts to design an artificial kidney 70 years ago during the Nazi occupation of his country. He moved to the U.S. in 1950, and did more of his seminal work at the Cleveland Clinic and the University of Utah.

Upon learning of Dr. Kolff's passing, his fellow kidney dialysis pioneer Kenneth Charles Appell commented, "A great man, whose contribution was necessary to the whole concept of hemodialysis. There had been work done on artificial kidneys before Kolff came along, but he refined the work and translated it into a useable machine that became the basis for all the equipment in use today.

Unfortunately, I never got to meet him, but from a personal standpoint I'm grateful -- without Willem Kolff's machines there wouldn't have been any reason for my own work, no way of using the AV fistula. And -- age 98, eh? Good for him!"