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A milestone paper in clinical dialysis. A half century celebration.

Access to the vascular system has been one of the major factors limiting the application of haemodialysis for the treatment of kidney failure. The history of vascular access parallels the development of dialysis technology. The celloidin-tubing dialysis machine by Abel et al. used glass cannulas that were perfectly apt for that milestone proof of concept study which demonstrated that haemodialysis can remove diffusible solutes from living animals [1, 2]. The Kolff dialyzer initially used a more much laborious procedure [3]. Blood had to be taken by venipuncture in 50-mL aliquots, dialyzed and returned to the patient. This was a lengthy, time-consuming procedure and the urgent need of developing continuous-flow methods was evident since the early days of dialysis. Artery and vein cannulation and heparin anti-coagulation offered a first solution for the successful application of haemodialysis as treatment of acute renal failure. With this approach, survival depended on the time to recovery of renal function face to face to progressive exhaustion of available vessels for cannulation. A late recovery precluded survival simply because it became impossible to access the patient’s circulation. Alwall and Norvitt [4] developed an ingenious arteriovenous glass shunt in 1948 but this was marred by major thrombotic problems; the lack of adequate material with limited thrombogenic potential remained an unresolved problem over the subsequent decade. In 1960, Quinton et al. [5] developed the first Teflon shunt allowing long-term vascular access with a reasonably low incidence of clotting episodes. The effectiveness and the safety of this approach was further improved by the use of silicone shunts. In 1962, anticipating the idea of arterio-venous fistula, Cimino proposed a new method allowing repeated dialyses by venipuncture in the arm [6]. In brief, he created intermittent tourniquet pressure in the arm by a sphygmomanometer, applied