A Cimino fistula, also Cimino-Brescia fistula, surgically created arteriovenous fistula and (less precisely) arteriovenous fistula (often

abbreviated An abbreviation () is a shortened form of a word or phrase, by any method including shortening, contraction, initialism (which includes acronym), or crasis. An abbreviation may be a shortened form of a word, usually ended with a trailing per ...

AV fistula or AVF), is a type of vascular access for

hemodialysis Hemodialysis, American and British English spelling differences#ae and oe, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of Kidney dialys ...

. It is typically a surgically created connection between an

artery An artery () is a blood vessel in humans and most other animals that takes oxygenated blood away from the heart in the systemic circulation to one or more parts of the body. Exceptions that carry deoxygenated blood are the pulmonary arteries in ...

and a

vein Veins () are blood vessels in the circulatory system of humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are those of the pulmonary and feta ...

in the arm, although there have been acquired arteriovenous fistulas which do not in fact demonstrate connection to an artery. Dialysehunt

Structure

The radiocephalic arteriovenous fistula (RC-AVF) is a shortcut created between

cephalic vein In human anatomy, the cephalic vein (also called the antecubital vein) is a superficial vein in the arm. It is the longest vein of the upper limb. It starts at the anatomical snuffbox from the radial end of the dorsal venous network of hand, a ...

and

radial artery In human anatomy, the radial artery is the main artery of the lateral aspect of the forearm. Structure The radial artery arises from the bifurcation of the brachial artery in the antecubital fossa. It runs distally on the anterior part of the ...

at the wrist. It is the recommended first choice for hemodialysis access. However, after a period of usage, failures can occur. Possible causes for failure are stenosis and thrombosis especially in diabetics and those with low blood flow such as due to narrow vessels, arteriosclerosis and advanced age. Reported patency of fistulae after 1 year is about 60%, when primary failures were included. Juxa-anastomotic site (venous segment that is between 2 and 5 cm distal to the anastomotic site) is the most common site of stenosis. One of the reasons affecting the rate of stenosis could be the anastomotic angle. In

computational fluid dynamics Computational fluid dynamics (CFD) is a branch of fluid mechanics that uses numerical analysis and data structures to analyze and solve problems that involve fluid dynamics, fluid flows. Computers are used to perform the calculations required ...

study, the ideal anastomotic angle should be less than 30 degrees to ensure

laminar flow Laminar flow () is the property of fluid particles in fluid dynamics to follow smooth paths in layers, with each layer moving smoothly past the adjacent layers with little or no mixing. At low velocities, the fluid tends to flow without lateral m ...

of the blood, thus prolong the

endothelial cell The endothelium (: endothelia) is a single layer of squamous endothelial cells that line the interior surface of blood vessels and lymphatic vessels. The endothelium forms an interface between circulating blood or lymph in the lumen and th ...

survival, and prevent smooth muscle proliferation within vessel wall, and clogging the vessel. However, in another study using

angiographic Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is perform ...

images of the juxta-anastomotic sites, the ideal anastomotic angle of less than 46.5 degrees was obtained. Surgically created AV fistulas work effectively because they: * Have high

volume flow rate In physics and engineering, in particular fluid dynamics, the volumetric flow rate (also known as volume flow rate, or volume velocity) is the volume of fluid which passes per unit time; usually it is represented by the symbol (sometimes \do ...

s (as blood takes the

path of least resistance In physics and mathematics, the path of least resistance is the pathway that provides the least resistance to forward motion by a given object or entity, among a set of alternative paths. The concept is often used to describe why an object or e ...

; it prefers the (low resistance) AV fistula over traversing (high resistance) capillary beds). * Use native blood vessels, which, when compared to synthetic grafts, are less likely to develop stenoses and fail.

History

The procedure was invented by doctors James Cimino and M. J. Brescia at the

Bronx Veterans Administration Hospital The James J. Peters VA Medical Center (also known as the Bronx Veterans Hospital) is a US Department of Veterans Affairs hospital complex located at 130 West Kingsbridge Road in West Fordham, Bronx, Fordham, The Bronx, Bronx, New York City. The ...

in 1966. Before the Cimino fistula was invented, access was through a

Scribner shunt Hemodialysis, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of dialysis achieves the extracorporeal removal of waste products such as cr ...

, which consisted of a

Teflon Polytetrafluoroethylene (PTFE) is a synthetic fluoropolymer of tetrafluoroethylene, and has numerous applications because it is chemically inert. The commonly known brand name of PTFE-based composition is Teflon by Chemours, a spin-off from ...

tube with a needle at each end. Between treatments, the needles were left in place and the tube allowed blood flow to reduce clotting. But Scribner shunts lasted only a few days to weeks. Frustrated by this limitation, James E. Cimino recalled his days as a

phlebotomist Phlebotomy is the process of making a puncture in a vein, usually in the arm, with a cannula for the purpose of drawing blood. The procedure itself is known as a venipuncture, which is also used for intravenous therapy. A person who performs a ...

(blood drawer) at

New York City New York, often called New York City (NYC), is the most populous city in the United States, located at the southern tip of New York State on one of the world's largest natural harbors. The city comprises five boroughs, each coextensive w ...

Bellevue Hospital Bellevue Hospital (officially NYC Health + Hospitals/Bellevue and formerly known as Bellevue Hospital Center) is a hospital in New York City and the oldest public hospital in the United States. One of the largest hospitals in the United States ...

in the 1950s when

Korean War The Korean War (25 June 1950 – 27 July 1953) was an armed conflict on the Korean Peninsula fought between North Korea (Democratic People's Republic of Korea; DPRK) and South Korea (Republic of Korea; ROK) and their allies. North Korea was s ...

veteran A veteran () is a person who has significant experience (and is usually adept and esteemed) and expertise in an job, occupation or Craft, field. A military veteran is a person who is no longer serving in the military, armed forces. A topic o ...

s showed up with

fistulas In anatomy, a fistula (: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") is an abnormal connection (i.e. tube) joining two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other ho ...

caused by trauma. Cimino recognized that these fistulas did not cause the patients harm and were easy places to get repeated blood samples. He convinced surgeon Kenneth Appell to create some in patients with

chronic kidney failure Chronic kidney disease (CKD) is a type of long-term kidney disease, defined by the sustained presence of abnormal kidney function and/or abnormal kidney structure. To meet criteria for CKD, the abnormalities must be present for at least three mo ...

and the result was a complete success. Scribner shunts were quickly replaced with Cimino fistulas, and they remain the most effective, longest-lasting method for long-term access to patients' blood for hemodialysis today.

References

{{Reflist

External links

A Milestone in Hemodialysis: James E. Cimino, MD, and the Development of the AV Fistula
Vascular surgery Renal dialysis