A pioneering physician looks back on one of the most important achievements of his life
“My wife says the only time she realizes I'm retired is on payday,” said James E. Cimino, MD, one recent morning, glancing down at his Mickey Mouse watch to make sure he was on schedule. Although he officially retired from his position as director of the Palliative Care Institute at CalvaryHospital in the Bronx in 2003, Dr. Cimino, 78, is lively, engaged, and continues to meet regularly with medical students and work on special projects. He's so busy, in fact, that when Renal & Urology News suggested getting together at a restaurant, Dr. Cimino replied, “I never go out to lunch.”
Why was Renal & Urology News eager to interview someone who is neither a practicing nephrologist nor a urologist? Quite simply, we wanted to learn about the person who was responsible for one of the most important treatment advances in the history of dialysis: the Cimino-Brescia arteriovenous (AV) fistula. Developed 40 years ago by Dr. Cimino and his colleagues Michael Brescia, MD, and Kenneth Appel, MD, the AV fistula is still among the most popular methods of vascular access for hemodialysis in the world.
A timely job offer
Dr. Cimino didn't set out to become a hemodialysis pioneer. In the late 1950s, there were very few trained nephrologists and no board of nephrology. The newly minted physician—a graduate of New YorkUniversity—was planning a career in pulmonary physiology.
After finishing a residency in internal medicine in Buffalo and completing a stint as chief of medical services at Orlando Air Force Base Hospital, however, Dr. Cimino wanted to move back to the Bronx, where he was raised. At 32, he was married and had three young children, and his father had just died. So when the BronxVeteransAdministrationHospital offered him a job setting up a dialysis unit, he was tempted.
In 1960, there were only three other dialysis machines in the city, at Mount Sinai, Bellevue, and Downstate, Dr. Cimino says. “And at that time, any place that did one dialysis session a week was considered a big center.”
Although the Bronx VA hospital planned to use the dialysis machine to treat patients with acute renal failure and poisoning, Dr. Cimino agreed to take the job only on the condition that he be allowed to establish a chronic dialysis program. “I believed the chronic program had a great future, and I didn't think we could keep a team of experts waiting around to handle just three or four poisonings a year,” he explains.
The Bronx VA hospital agreed, and Dr. Cimino and a colleague, Ruben Aboody, a technologist, began dialyzing patients at the bedside, then in a partitioned area in the corridor of the third-floor medical unit using a Kolff twin-coil artificial kidney.
The ‘Achilles heel' of hemodialysis
Dr. Cimino and Mr. Aboody dialyzed their first chronic renal-failure patient in December 1960, gaining vascular access to the man's circulatory system by repeatedly inserting cannulae into his blood vessels. Unfortunately, the patient survived only a few days. “Vascular access was the Achilles heel of chronic hemodialysis,” Dr. Cimino says. Back then, he explains, an artery and a vein were damaged every time the patient was hooked up to the dialyzer. A patient could receive only about half a dozen treatments before doctors would literally run out of places to connect a vessel to the machine.
Vascular access improved in 1959 when Belding Scribner, MD, de-veloped the “Scribner-Quinton shunt”—a U-shaped Teflon tube used to connect the artery and vein that was left in place between treatments. But Scribner-Quinton shunts usually lasted a few months or less, and were far from ideal. “Everyone was having problems with them—including Scribner,” Dr. Cimino says. “The shunts dislodged, and there were difficulties with clotting, skin necrosis, bleeding, and infection.”
The external shunts were also difficult for patients to tolerate psychologically. Those who lost one felt that their ‘lifelines' had been cut off and often became severely depressed. Moreover, a lost shunt meant hospitalization and a painful, expensive recannulation procedure.
While pondering a possible solution to these problems, Dr. Cimino recalled his days working as a phlebotomist at the BellevueHospital blood bank during medical school. “The rapid blood flows we obtained from a needle connected to a Vacutainer—a vacuum bottle—had left an impression on me, and I thought, ‘Why don't we take these veterans, who have big, bulging veins, and put the needles in those veins?'”
In 1961, Dr. Brescia joined Dr. Cimino and Mr. Aboody as a third-year resident. They tried this vein-to-vein dialysis approach in several patients. While the team had some modest success with this method, the 250 to 300 cc/min blood flows necessary for optimal dialysis could be sustained only when patients were either overhydrated or in congestive heart failure. The technique was reported in the New England Journal of Medicine in 1962.
Dr. Cimino began to wonder whether the vein-to-vein technique could be salvaged if he and his colleagues could take advantage of the rapid blood flow and accompanying venous distention that occurred in the presence of a surgically created AV fistula.
He knew that some of the earliest surgical fistulae had been created in the 1930s at the Mayo Clinic. Doctors there were trying to promote collateral circulation in children with polio whose legs were paralyzed and not growing. Doctors thought that if they could get adequate blood flow to the limbs before the epiphyses closed, maybe they could get the children's legs to grow. “To my knowledge, prior to that, all AV fis-tulae were traumatic in nature,” Dr. Cimino relates. “And because we knew about the possible hazards related to fistulae, including heart failure, we did this with some trepidation.”
When Dr. Cimino discussed the idea of creating AV fistulae for hemodialysis with his colleagues, they were cautiously enthusiastic. Dr. Appel “was eager to try the technique,” as was Dr. Brescia. More-over, patients “were begging to be kept alive,” Dr. Cimino says. “We were bold in using a procedure that had always been considered physiologically abnormal, but without adequate vascular access our patients were doomed.”
Under-the-skin solution
Briefly, this is how the AV fistula operation is performed: After ad-ministering local anesthesia, the surgeon makes a small incision over the patient's radial pulse, mobilizes the radial artery, and divides and ligates adjacent arterial branches. The surgeon then mobilizes the largest available neighboring vein and brings the vessels side by side. After making longitudinal incisions in corresponding lateral surfaces of both artery and vein, the surgeon performs a side-to-side anastomosis. Today, there are a number of variations of this surgical procedure.
Originally, dialysis was performed the day following surgery. To do this, two sites were selected for venipuncture, usually at the cephalic vein in the upper arm and in the forearm just below the antecubital fossa. Venipuncture is performed at both sites; needles are attached at both sites via a twin dialysis catheter system, fastened to the patient's arm with adhesive tape and attached to an IV drip. The twin catheters are disconnected from the IV drip, and heparin is injected directly into the catheters. The dialyzer tubing and the catheters are connected, the distal needle being used to withdraw blood from the patient's arm for delivery into the dialyzer, and the proximal needle for returning blood to the patient.
First failure, then success
The Cimino team's first AV fistula dialysis attempt failed. Later, they realized it had failed for the same reason the original vein-to-vein technique had failed. “The patient had been prepared so diligently before the procedure that we re-moved too much fluid,” Dr. Cimino says. “His blood pressure was in-adequate for keeping blood flowing through the newly created fistula.” Once the pressure was adjusted, the fistula performed as expected.
After a period of trial and error, Dr. Cimino and his team figured out how to maintain adequate blood flow by using carefully placed tourniquets. They also found that despite their fears, patients' heart functions either remained stable or improved following the creation of a fistula. Soon, most Scribner shunts were replaced with Cimino-Brescia fistulas.
By April 1966, Dr. Cimino had enough experience with the AV fistula needle technique to present the result of his work with 14 patients at the XII Congress of the American Society for Artificial Internal Organs. To his surprise, the audience reacted with complete indifference.
“There was no comment!”
Dr. Cimino recalls, still sounding chagrined decades after the fact. “I thought, they just don't get it.' One doctor from the United Kingdom, who was active in promoting fancy percutaneous punctures of the femoral artery, said, ‘Once you get 100 patients call me.'”
Today, Dr. Cimino can laugh about that brush-off. “A better mousetrap eventually wins people over,” he says. “Our AV fistula proved to be more effective and safer” than the shunt method. “In 1968 I made a grand tour of Europe, going all the way from Naples to Stockholm as guest
of the Swedish Medical Society.”
Dr. Cimino stresses that the success of this program was due to the effort of the entire team, most notably that of Drs. Brescia and Appel. Other important members of the team were Mr. Aboody, Wendy Kolesha, RN (deceased), and Baruch Hurwich, MD (deceased).
Time to move on
After his contribution to the field of hemodialysis was accepted, Dr. Cimino felt it was time to
move on. For one thing, he had long known that he wanted to cut back at the Bronx VA Hospital so he could start a private practice. For another, he had begun to get involved with the House of Calvary, a nursing home in the West Bronx administered by the Dominican Sisters of the Sick Poor. “They took care of terminally ill children and adults,” says Dr. Cimino of the institution that became CalvaryHospital. “At that time Bertram Bell and I had started a practice in White Plains, N.Y. and he knew that the Sisters needed medical assistance. We both grew up in the Bronx and wanted to do something for inner-city people.”
Drs. Brescia and Appel soon joined Dr. Cimino in this new en-deavor. Dr. Cimino began working at Calvary as an attending physician in 1962 while still at the Bronx VA, where he continued as Director of Nephrology Services until 1967 and then of the Hemodialysis Unit until 1970. He continued as a consultant through most of 1978. He also became Calvary's medical director in the mid-1960s and was appointed Director of the Palliative Care Institute in 1994.
In recalling the development of the AV fistula, Dr. Cimino says he had no idea his technique would continue to be popular so many years later. “I thought the real advances were going to be in chemistry,” he says, “and that scientists would develop a pill” to help patients with end-stage renal disease (ESRD).
Although that hasn't happened, Dr. Cimino says the advances that have been made are important. “In those early days we didn't understand the metabolism of calcium and phosphorus; now we can avoid many of the problems we used to have. We also didn't have erythropoietin. Now we do, so we can prevent anemia. And we've learned much more about the power of the parathyroid gland and how to control it.”
In addition to his renal career, Dr. Cimino has taught medical students for over 50 years and taught a course in advanced medical nutrition at New YorkUniversity for more than 20 years. Although he has spent much of his career caring for terminal cancer patients, Dr. Cimino clearly has a soft spot for the ESRD patients he helped many years ago and the ones that, in part because of his efforts, are still alive and functioning well today. “We're not just keeping them alive,” he says. “The fact that we don't think of people on dialysis as being terminally ill speaks to the fact that a great deal of progress has been made.”