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Introduction to Vascular Access


During the darkest days of World War II, William Kolff developed a rotating drum-type "artificial kidney" and began dialysis treatments on his acute renal failure patients in the basement of his hospital in Holland, under the noses of the occupying Nazi forces (Kolff, 1944). The goals of UWEB and organizations like it are to design and fabricate materials that: 1 Heal in a manner analogous to normal tissue healing and are integrated into the body. 2 Embody engineering principles that lead to rational design of new biomaterials. 3 Eliminate the collagenous encapsulation that interferes with implant function. 4 Provide transfer technologies for improved materials and devices to industry. 5 Provide training for a new generation of interdisciplinary scientist-engineers encompassing materials science, molecular engineering, molecular biology, cell biology, and medicine, as reflected in the title of a recent conference "How to Build a Blood Vessel."

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									                             P A P E R S                A N D               O P I N I O N S

     Introduction to Vascular Access
Robert 0. Hickman, MD and David Tapper, MD

           lthough fascination with human blood probably be-           nard was performing sophisticated studies of cardiac catheter-
           gan with the first human (or the first laceration), the       ization in animals, and later described myocardial perforation
           story of vascular access must properly begin with           as its first complication. The same era saw the development of
William Harvey (1628), who, through a series of elegant exper-         the first “hypodermic” needle and syringe (Schmidt, 1959).
iments, first defined the structure and function of the circula-            In the early 1900ʼs Landsteiner described the antigen and an-
tory system. Bloodletting is described in ancient Egyptian and         tibody system, (ABO) (Schmidt, 1959) sodium citrate was in-
Arabic texts, and the Old Testament contains veiled references         troduced as an anti-coagulant, and sterile needles, tubing, and
to blood transfusion (Zimmerman, 1989), but it remained for            continuous intravenous fluid infusions became commonplace.
Harvey and his students to begin scientific investigations of           Soon thereafter, the “catheter through the needle” became the
blood volume and blood pressure. These studies depended on             first long-term intravenous device, followed by the safer, more
crude metal tubes as cannulae. Several reports of blood transfu-       comfortable, and more durable “cannula over the needle.”
sion appeared in the early 1600s, with results ranging from “no           During the darkest days of World War II, William Kolff
ill effect” to “very effective.” (Schmidt, 1959; Dutton, 1924;         developed a rotating drum-type “artificial kidney” and began
Annan, 1939).                                                          dialysis treatments on his acute renal failure patients in the
   Robert Boyle and Sir Christopher Wren (1632-1723), (Schmidt,        basement of his hospital in Holland, under the noses of the oc-
1959; Annan, 1939; Plumer, 1982), introduced more sophisti-            cupying Nazi forces (Kolff, 1944). He was forced to rely on
cated cannulae crafted from the quill of a birdʼs feather. By the      repeated needle punctures or actual cut-downs to access the
late 1600ʼs they had performed animal experiments involving the        femoral arteries and peripheral veins. In spite of these technical
injection of intravenous narcotics, and the popular press was pub-     obstacles, the concept of dialysis became a reality due to his
lishing reports (and cartoons) detailing animal-to-human trans-        genius and heroism.
fusion. By 1697 religious and secular opposition to the practice          The modern era of vascular access to achieve arterio-venous
of “xeno-transfusion” culminated in a ban on all transfusion for       communication began in 1949, when Nils Alwall of Sweden
most of Europe. Bloodletting, however, flourished.                      developed a permanent glass conduit connecting artery to vein.
   It would be another 150 years before observations and stud-         But it was not until 1960 that Seattle nephrologist Belding Scrib-
ies on the massive fluid and electrolyte losses of cholera pa-          ner and engineer Wayne Quinton (Quinton and Dillard, 1960)
tients stimulated the investigation of intravenous fluid thera-         developed an external arterio-venous shunt made of custom-fit-
py. In 1831 William OʼShaughnessy coined the term “black               ted Teflon tubes at the University of Washington. This device
blood” to describe the result of severe salt and water deple-          made vascular access easy enough to allow dialysis every day,
tion (OʼShaughnessy, 1832). Thomas Latta, (1831) used the              if necessary, and truly began the era of the artificial kidney.
pandemic of cholera in the 1880ʼs to demonstrate that fluid             Soon Silastictm tubing replaced Teflontm, and the resulting shunt
replacement was the necessary and sufficient treatment, con-            launched the end-stage renal disease program that currently sup-
cluding that “one-third of his moribund patients were restored         ports three hundred thousand-plus patients in the United States
to the wor
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