"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.