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!"