- Email: [email protected]
Introduction to Vascular Access
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)NTRODUCTION TO 6ASCULAR !CCESS Robert 0. Hickman, MD and David Tapper, MD
!
lthough fascination with human blood probably began with the first human (or the first laceration), the story of vascular access must properly begin with William Harvey (1628), who, through a series of elegant experiments, first defined the structure and function of the circulatory system. Bloodletting is described in ancient Egyptian and Arabic texts, and the Old Testament contains veiled references to blood transfusion (Zimmerman, 1989), but it remained for Harvey and his students to begin scientific investigations of blood volume and blood pressure. These studies depended on crude metal tubes as cannulae. Several reports of blood transfusion appeared in the early 1600s, with results ranging from “no ill effect” to “very effective.” (Schmidt, 1959; Dutton, 1924; Annan, 1939). Robert Boyle and Sir Christopher Wren (1632-1723), (Schmidt, 1959; Annan, 1939; Plumer, 1982), introduced more sophisticated cannulae crafted from the quill of a birdʼs feather. By the late 1600ʼs they had performed animal experiments involving the injection of intravenous narcotics, and the popular press was publishing reports (and cartoons) detailing animal-to-human transfusion. By 1697 religious and secular opposition to the practice of “xeno-transfusion” culminated in a ban on all transfusion for most of Europe. Bloodletting, however, flourished. It would be another 150 years before observations and studies on the massive fluid and electrolyte losses of cholera patients stimulated the investigation of intravenous fluid therapy. In 1831 William OʼShaughnessy coined the term “black blood” to describe the result of severe salt and water depletion (OʼShaughnessy, 1832). Thomas Latta, (1831) used the pandemic of cholera in the 1880ʼs to demonstrate that fluid replacement was the necessary and sufficient treatment, concluding that “one-third of his moribund patients were restored to the world.” Intravenous infusion therapy was not universally accepted, perhaps due to well-meaning but ill-fated infusions of un-sterile water, cowʼs milk, albumin, and various salt concentrations. One can imagine a significant mortality rate related to infection, air embolus, hemolysis, hyponatremia, and anaphylacsis. However, as early as 1885 the French physiologist Claude Ber-
Correspondence concerning this article should be addressed to [email protected] DOI: 10.2309/java.14-2-4
74
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JAVA
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Vol 14 No 2
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nard was performing sophisticated studies of cardiac catheterization in animals, and later described myocardial perforation as its first complication. The same era saw the development of the first “hypodermic” needle and syringe (Schmidt, 1959). In the early 1900ʼs Landsteiner described the antigen and antibody system, (ABO) (Schmidt, 1959) sodium citrate was introduced as an anti-coagulant, and sterile needles, tubing, and continuous intravenous fluid infusions became commonplace. Soon thereafter, the “catheter through the needle” became the first long-term intravenous device, followed by the safer, more comfortable, and more durable “cannula over the needle.” 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). He was forced to rely on repeated needle punctures or actual cut-downs to access the femoral arteries and peripheral veins. In spite of these technical obstacles, the concept of dialysis became a reality due to his genius and heroism. The modern era of vascular access to achieve arterio-venous communication began in 1949, when Nils Alwall of Sweden developed a permanent glass conduit connecting artery to vein. But it was not until 1960 that Seattle nephrologist Belding Scribner and engineer Wayne Quinton (Quinton and Dillard, 1960) developed an external arterio-venous shunt made of custom-fitted Teflon tubes at the University of Washington. This device made vascular access easy enough to allow dialysis every day, if necessary, and truly began the era of the artificial kidney. Soon Silastictm tubing replaced Teflontm, and the resulting shunt launched the end-stage renal disease program that currently supports three hundred thousand-plus patients in the United States alone. The Cimino-Brescia fistula (Brecia, Cimino, Appel, and Hurwich, 1966) was introduced in 1996, making the external A-V shunt obsolete. Chronic hemodialysis patients now depend on this fistula, or on synthetic vascular grafts. In the late 1960ʼs Dr. Stanley Dudrick and others (Dudrick, Wilmore, Vars, and Rhoads, 1968) introduced the concept of total parenteral nutrition to support patients who would otherwise have succumbed to medical or surgical conditions affecting their ability to utilize oral nutrition. Due to the high osmolality of the parenteral fluids, long-term, secure and safe central vascular access was required. Belding Scribner introduced the use of the Broviac central venous catheter (Broviac,
2009
Cole, and Scribner, 1973) which was designed for long-term home nutritional support which he initially called the “artifical gut.” The combination of a Silastic “cuffed” catheter (Broviac et al., 1973; Scribner et al., 1970) implanted via a long, subcutaneous tunnel provided a secure infection-resistant devise. The vascular access saga might well have ended here. The Broviac catheter was returned to its developers after an 18-month trial with a medical device manufacturer as “not commercially viable.” However, the manufacturer had not anticipated rapid advances in cancer chemotherapy and bonemarrow transplantation. Up until the 1960s, central venous access had been used only in the most acute emergencies, and for very limited time periods, due to the inevitable development of thrombosis and infection with prolonged placement. But in 1973 (Hickman et al., 1979) the doctors at the bone marrow transplant unit of the Fred Hutchinson Cancer Research Center in Seattle were desperate. One of their bone marrow transplant patients, moderately obese, had exhausted all possibilities of peripheral vascular access and was urgently in need of multiple intravenous support. Their daring decision to place a Broviac catheter not only facilitated the therapy but provided a considerable degree of comfort to their patient. This experience also marked a watershed in the support of cancer chemotherapy and transplant patients everywhere. Central venous catheters have become an essential tool of the nephrologist, the gastroenterologist, the intensivist, the oncologist, and are now routinely used on general medical and surgical services throughout the world. Double, and even triple-lumen catheters have become commonplace. Over the last forty years the favorable risk-benefit ratio of these devices has rendered them not merely “commercially viable,” but resoundingly successful. The pioneering work of Dr. E. Donnall Thomas (Hickman et al., 1979) and his associates at the “Fred Hutch” has demonstrated the benefits of continuous central venous access even in the most high-risk patients. Today, the placement of a suitable vascular access device is one of the first interventions in a newly-diagnosed cancer patient. Children receiving chemotherapy say it best: “No more pokes!” We have not yet reached the final chapter of this success story, for the search for more bio-compatible catheter materials is ongoing. Current research efforts are investigating incorporation of antibiotics or other anti-infective materials into the polyurethane and silicone substrates themselves. The recently formed University of Washington Engineered Biomaterials, (UWEB) a consortium of some thirty-five corporations, the National Science Foundation, and several universities) has embarked on an eleven-year initiative in biomaterials engineering. In the words of the UWEBʼs mission statement, “Biomaterials engineering is the science and art of making, with economy and elegance, materials and devices for interaction with biological systems, such that they can specifically trigger desired biological processes, be used with safety, and resist the mechanical and degradative forces to which they may be subjected.” 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
2009
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.” References Annan, G.L. (1939). An exhibition of books on the growth of our knowledge of blood transfusions. Bulletin New York Academy of Science, 15,622-632. Bernard, C. (1870). Lessons on the phenomena of life common to animals and vegetables. Brecia, M., Cimino, J.E., Appel, K., Hurwich, B.J. (1966). Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. New England Journal of Medicine, 275,1089-1092. Broviac, J.W., Cole, J.J., and Scribner, B.H. (1973). A silicone rubber atrial catheter for prolonged parenteral alimentation. Surgical Gynecology and Obstetrics, 136,602-606. Dudrick, J.L., Wilmore, D.W., Vars, H.M., and Rhoads, J.E. (1968). Long-term total parenteral nutrition with growth, development and positive nitrogen balance. Surgery, 64,134-142. Dutton, W.F. (1924). Intravenous therapy: Its application in the modern practice of medicine. Philadelphia: FA Davis. Harvey, W. (1628). De Motu Cordis, Frankfurt Hickman, R.O., Buckner, C.D., Clift, R.A., Sanders, J.E., Stewart, P., and Thomas, E.D. (1979). A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surgical Gynecology and Obstetrics, 148, 871-875. Kloff, W. (1944). The Artificial Kidney. Acta Medica Scandinavica, 117,120. Latta, T.A. (1831). Malignant cholera: Relative to the treatment of cholera by copious injection of aqueous and saline into the veins. Lancet, 2,274-277. Oʼshaughnessy, W.B. (1832). Report on the chemical pathology of the malignant cholera. London: S. Highley. Personal communication. Buddy Ratner Ph.D. Director, University of Washington Engineered Biomaterials. Box 351720, University of Washington, Seattle, Washington. Plumer, A. (1982). Principles and practices of intravenous therapy. Boston: Little, Brown. Quinton, W., and Scribner, B. (1960). Cannulation of blood vessels for prolonged hemodialysis. Transaction- American Society for Artificial Internal Organs, 6,104-113. Schmidt, J.E. (1959) Medical Discoveries who and when. (p. 59). Springfield, Il. C. Thomas Scribner, B.H., Cole, J.J., Christopher, T.G., Vizzo, J.E., Atkins, R.C., and Blagg, C.R. (1970). Long-term total parenteral nutrition; the concept of an artificial gut. Journal of the American Medical Association, 212,457-463. Zimmerman J. (1989). History and current application of intravenous therapy in children. Pediatric Emergency Care, 5, 120-127
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Vol 14 No 2
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JAVA
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75
)NTRODUCTION TO 6ASCULAR !CCESS Robert 0. Hickman, MD and David Tapper, MD
!
lthough fascination with human blood probably began with the first human (or the first laceration), the story of vascular access must properly begin with William Harvey (1628), who, through a series of elegant experiments, first defined the structure and function of the circulatory system. Bloodletting is described in ancient Egyptian and Arabic texts, and the Old Testament contains veiled references to blood transfusion (Zimmerman, 1989), but it remained for Harvey and his students to begin scientific investigations of blood volume and blood pressure. These studies depended on crude metal tubes as cannulae. Several reports of blood transfusion appeared in the early 1600s, with results ranging from “no ill effect” to “very effective.” (Schmidt, 1959; Dutton, 1924; Annan, 1939). Robert Boyle and Sir Christopher Wren (1632-1723), (Schmidt, 1959; Annan, 1939; Plumer, 1982), introduced more sophisticated cannulae crafted from the quill of a birdʼs feather. By the late 1600ʼs they had performed animal experiments involving the injection of intravenous narcotics, and the popular press was publishing reports (and cartoons) detailing animal-to-human transfusion. By 1697 religious and secular opposition to the practice of “xeno-transfusion” culminated in a ban on all transfusion for most of Europe. Bloodletting, however, flourished. It would be another 150 years before observations and studies on the massive fluid and electrolyte losses of cholera patients stimulated the investigation of intravenous fluid therapy. In 1831 William OʼShaughnessy coined the term “black blood” to describe the result of severe salt and water depletion (OʼShaughnessy, 1832). Thomas Latta, (1831) used the pandemic of cholera in the 1880ʼs to demonstrate that fluid replacement was the necessary and sufficient treatment, concluding that “one-third of his moribund patients were restored to the world.” Intravenous infusion therapy was not universally accepted, perhaps due to well-meaning but ill-fated infusions of un-sterile water, cowʼs milk, albumin, and various salt concentrations. One can imagine a significant mortality rate related to infection, air embolus, hemolysis, hyponatremia, and anaphylacsis. However, as early as 1885 the French physiologist Claude Ber-
Correspondence concerning this article should be addressed to [email protected] DOI: 10.2309/java.14-2-4
74
|
JAVA
|
Vol 14 No 2
|
nard was performing sophisticated studies of cardiac catheterization in animals, and later described myocardial perforation as its first complication. The same era saw the development of the first “hypodermic” needle and syringe (Schmidt, 1959). In the early 1900ʼs Landsteiner described the antigen and antibody system, (ABO) (Schmidt, 1959) sodium citrate was introduced as an anti-coagulant, and sterile needles, tubing, and continuous intravenous fluid infusions became commonplace. Soon thereafter, the “catheter through the needle” became the first long-term intravenous device, followed by the safer, more comfortable, and more durable “cannula over the needle.” 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). He was forced to rely on repeated needle punctures or actual cut-downs to access the femoral arteries and peripheral veins. In spite of these technical obstacles, the concept of dialysis became a reality due to his genius and heroism. The modern era of vascular access to achieve arterio-venous communication began in 1949, when Nils Alwall of Sweden developed a permanent glass conduit connecting artery to vein. But it was not until 1960 that Seattle nephrologist Belding Scribner and engineer Wayne Quinton (Quinton and Dillard, 1960) developed an external arterio-venous shunt made of custom-fitted Teflon tubes at the University of Washington. This device made vascular access easy enough to allow dialysis every day, if necessary, and truly began the era of the artificial kidney. Soon Silastictm tubing replaced Teflontm, and the resulting shunt launched the end-stage renal disease program that currently supports three hundred thousand-plus patients in the United States alone. The Cimino-Brescia fistula (Brecia, Cimino, Appel, and Hurwich, 1966) was introduced in 1996, making the external A-V shunt obsolete. Chronic hemodialysis patients now depend on this fistula, or on synthetic vascular grafts. In the late 1960ʼs Dr. Stanley Dudrick and others (Dudrick, Wilmore, Vars, and Rhoads, 1968) introduced the concept of total parenteral nutrition to support patients who would otherwise have succumbed to medical or surgical conditions affecting their ability to utilize oral nutrition. Due to the high osmolality of the parenteral fluids, long-term, secure and safe central vascular access was required. Belding Scribner introduced the use of the Broviac central venous catheter (Broviac,
2009
Cole, and Scribner, 1973) which was designed for long-term home nutritional support which he initially called the “artifical gut.” The combination of a Silastic “cuffed” catheter (Broviac et al., 1973; Scribner et al., 1970) implanted via a long, subcutaneous tunnel provided a secure infection-resistant devise. The vascular access saga might well have ended here. The Broviac catheter was returned to its developers after an 18-month trial with a medical device manufacturer as “not commercially viable.” However, the manufacturer had not anticipated rapid advances in cancer chemotherapy and bonemarrow transplantation. Up until the 1960s, central venous access had been used only in the most acute emergencies, and for very limited time periods, due to the inevitable development of thrombosis and infection with prolonged placement. But in 1973 (Hickman et al., 1979) the doctors at the bone marrow transplant unit of the Fred Hutchinson Cancer Research Center in Seattle were desperate. One of their bone marrow transplant patients, moderately obese, had exhausted all possibilities of peripheral vascular access and was urgently in need of multiple intravenous support. Their daring decision to place a Broviac catheter not only facilitated the therapy but provided a considerable degree of comfort to their patient. This experience also marked a watershed in the support of cancer chemotherapy and transplant patients everywhere. Central venous catheters have become an essential tool of the nephrologist, the gastroenterologist, the intensivist, the oncologist, and are now routinely used on general medical and surgical services throughout the world. Double, and even triple-lumen catheters have become commonplace. Over the last forty years the favorable risk-benefit ratio of these devices has rendered them not merely “commercially viable,” but resoundingly successful. The pioneering work of Dr. E. Donnall Thomas (Hickman et al., 1979) and his associates at the “Fred Hutch” has demonstrated the benefits of continuous central venous access even in the most high-risk patients. Today, the placement of a suitable vascular access device is one of the first interventions in a newly-diagnosed cancer patient. Children receiving chemotherapy say it best: “No more pokes!” We have not yet reached the final chapter of this success story, for the search for more bio-compatible catheter materials is ongoing. Current research efforts are investigating incorporation of antibiotics or other anti-infective materials into the polyurethane and silicone substrates themselves. The recently formed University of Washington Engineered Biomaterials, (UWEB) a consortium of some thirty-five corporations, the National Science Foundation, and several universities) has embarked on an eleven-year initiative in biomaterials engineering. In the words of the UWEBʼs mission statement, “Biomaterials engineering is the science and art of making, with economy and elegance, materials and devices for interaction with biological systems, such that they can specifically trigger desired biological processes, be used with safety, and resist the mechanical and degradative forces to which they may be subjected.” 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
2009
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.” References Annan, G.L. (1939). An exhibition of books on the growth of our knowledge of blood transfusions. Bulletin New York Academy of Science, 15,622-632. Bernard, C. (1870). Lessons on the phenomena of life common to animals and vegetables. Brecia, M., Cimino, J.E., Appel, K., Hurwich, B.J. (1966). Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. New England Journal of Medicine, 275,1089-1092. Broviac, J.W., Cole, J.J., and Scribner, B.H. (1973). A silicone rubber atrial catheter for prolonged parenteral alimentation. Surgical Gynecology and Obstetrics, 136,602-606. Dudrick, J.L., Wilmore, D.W., Vars, H.M., and Rhoads, J.E. (1968). Long-term total parenteral nutrition with growth, development and positive nitrogen balance. Surgery, 64,134-142. Dutton, W.F. (1924). Intravenous therapy: Its application in the modern practice of medicine. Philadelphia: FA Davis. Harvey, W. (1628). De Motu Cordis, Frankfurt Hickman, R.O., Buckner, C.D., Clift, R.A., Sanders, J.E., Stewart, P., and Thomas, E.D. (1979). A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surgical Gynecology and Obstetrics, 148, 871-875. Kloff, W. (1944). The Artificial Kidney. Acta Medica Scandinavica, 117,120. Latta, T.A. (1831). Malignant cholera: Relative to the treatment of cholera by copious injection of aqueous and saline into the veins. Lancet, 2,274-277. Oʼshaughnessy, W.B. (1832). Report on the chemical pathology of the malignant cholera. London: S. Highley. Personal communication. Buddy Ratner Ph.D. Director, University of Washington Engineered Biomaterials. Box 351720, University of Washington, Seattle, Washington. Plumer, A. (1982). Principles and practices of intravenous therapy. Boston: Little, Brown. Quinton, W., and Scribner, B. (1960). Cannulation of blood vessels for prolonged hemodialysis. Transaction- American Society for Artificial Internal Organs, 6,104-113. Schmidt, J.E. (1959) Medical Discoveries who and when. (p. 59). Springfield, Il. C. Thomas Scribner, B.H., Cole, J.J., Christopher, T.G., Vizzo, J.E., Atkins, R.C., and Blagg, C.R. (1970). Long-term total parenteral nutrition; the concept of an artificial gut. Journal of the American Medical Association, 212,457-463. Zimmerman J. (1989). History and current application of intravenous therapy in children. Pediatric Emergency Care, 5, 120-127
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Vol 14 No 2
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JAVA
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75