Long-term experience with Thomas shunt

Editor's note Please see also editorial note by Krönung pp. 1762–1763 and original article by Coronel et al. pp. 1845–1849

Jürgen Bommer

Medizinische Universitäts Klinik, Heidelberg, Germany

During the pioneer period of dialysis therapy led by Kolff, Alwall and others, vascular access was already a difficult problem. The bilateral puncture of the cubital veins did not allow for long-term chronic haemodialysis therapy. The double-lumen catheters recommended by Battezatti et al. in 1953 [1], and later by McIntosh et al. [2] in 1959, and Bisson et al. [3] in 1965, had to be installed by venous section via vena saphena magna in the femoral vein. Introduction of Teflon–Silastic catheters via the percutaneous puncture technique facilitated vascular access for intermittent haemodialysis [4]. Other access modalities to central veins, such as puncture of the subclavian vein [5] and various puncture techniques of the jugular vein were also recommended. Because of clotting complications and infections, these vascular techniques were used for weeks or months, at best.

The Quinton–Scribner shunt provided a great step forward in 1960 [6]. The Teflon–Silastic construction offered a useful vascular access in the upper and lower limbs of dialysis patients that lasted for many months. In 1962, Quinton et al. [7] reported that these shunts had functioned without complications for a mean of 11.3 months. After this the Quinton shunt was used in nearly all dialysis centres throughout the world. In addition several modifications were developed during the following years, including the ‘single-break shunt’ of Sewitt, the Teflon–Silastic shunt without subcutaneous U-turns, and the ‘winged inline shunt’ of Ramirez. However, these modifiations required a Teflon-vessel tip which favoured thrombus formation. In contrast the use of these tips could be avoided in the Thomas shunt [8]. This shunt uses a Dacron patch at both ends of the Silastic tubing which has to be fixed end-to-side on the femoral artery or vein by a careful suture of the patch. In this way, the Silastic shunt is connected smoothly without vessel tips, and due to optimal infolding of the shunt, necrosis of vessel walls following ligation around vessel tips can be prevented. Furthermore, the wide aperture reduces turbulence of blood entering the arterial and venous vessel beds. The Dacron patch of the Thomas shunt fixes the Silastic prosthesis very safely and reduces the frequency of infection.

A modification of the Thomas shunt by Allen and Jacobson, using vessels from the upper limb, was little used because at the same time, Brescia and Cimino [9] created the popular subcutaneous arteriovenous fistula. This Brescia–Cimino shunt and its subsequent modifications are the generally preferred mode of vascular access at present. However, all subcutaneous vascular access modalities using autologous vessels or grafts require a suitable vein and artery in the upper part of the patient's body. Unfortunately most of these access modes cannot be used in the lower extremities, except for certain types such as the graft-loop in the proximal part of the thigh.

Because uraemic patients are increasingly older at the onset of haemodialysis therapy, and because the percentage of diabetic patients is increasing in Western countries, there are fewer blood vessels available for vascular access. This is perhaps one important reason why our American colleagues use vascular grafts in more than 60% of dialysis patients (DOPPS, Dialysis Outcomes and Practice Patterns Study). Furthermore, improved devices and quality of dialysis has resulted in a longer survival of patients and longer use of vascular access. This has worsened to some extent problems of vascular access in patients under maintenance haemodialysis.

Therefore, vascular access still represents the Achilles heel in current haemodialysis therapy. Due to a lack of suitable peripheral arteries and veins in the upper limbs, the number of patients dialysed via Permcaths has increased continuously during recent years. Central venous catheters in the jugular vein, subclavian vein, or other thoracic veins including the atrium produce the risk of severe infection followed by septicaemia, septic spondylitis, endocarditis and others. This explains why some surgeons have returned to more or less forgotten vascular modalities such as the Thomas shunt. Naturally, this access cannot be recommended without restriction, because like all transcutaneous Silastic tubings, it carries the possibility of infection. The study by Coronel et al. (pp. 1845–1849) concludes that the infection rate may be less frequent and long-term function may be rather good compared with central vein Permcaths. This report may stimulate nephrologists and vascular surgeons to consider methods that are no longer in use, and to re-evaluate these modalities of vascular access, at least in patients who have no regular vascular access left in the upper part of the body.

Notes

Correspondence and offprint requests to: J. Bommer, Medizinische Universitäts Klinik, Bergheimerstrasse 56, D-69115 Heidelberg, Germany. Back

References

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  9. Brescia MJ, Cimino JE, Appoel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med1966; 275: 1089[ISI][Medline]




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