Cimino brescia shunt

In 1966, Brescia et al. described the so-called Cimino- Brescia shunt for the first time (Hepp 2016). Originally, a forearm vein was connected to a forearm artery by a side-to-side anastomosis, in the meantime, the anastomosis is performed by an end-to- side anastomosis (Geberth 2011).

A Cimino-Brescia shunt is a surgically placed vascular access between an artery (usually the radial artery leaving the brachial artery) and a forearm vein as an access possibility for chronic hemodialysis (Burchardi 2004). The shunt is also known as "dialysis access" (Kasper 2015).

The Cimino- Brescia shunt is still the gold standard for vascular access for continuous dialysis treatment (Hepp 2016)

The anastomosis leads to an arterialization of the vein. This allows access to large needles (e.g. between 15 - 17 gauge [Gerberth 2011]) and thus large volumes of up to 800 ml / min (Kuhlmann 2015) during dialysis (Kasper 2015).

Different complications can occur on the shunt in the course of the disease:

infections: Infections in the area of the catheter are the main cause of all bacteremias in up to 50% of cases. Predisposing factors for an infection are:

- Edema in the area of the puncture site

- severe pruritus in the affected arm

- malformed bruises

- Puncture for purposes other than dialysis (Kuhlmann 2015)

When infections occur, the primary cause is usually a local redness and swelling in the area of the shunt. In the further course of the disease it can occur:

- shunt thrombosis

- Arrosion bleeding

- septic scattering with:

- endocarditis

- Abscesses in the area of the entire body (Kuhlmann 2015)

Shunt thromboses: Thromboses are the most common cause of a shunt becoming unusable. Although a thrombosis in the Cimino- Brescia shunt could be removed by catheter intervention, the cause of the thrombosis is decisive for the further use of the catheter.

Causes of thrombosis can be:

- during anaesthesia, an intermittent drop in blood pressure results in a reduced blood flow

- Occurrence of stenoses in the course of the vessel or intraluminal (dilatation or surgical removal of the constriction is possible)

- acquired disorders of the coagulation system (e.g. formation of antibodies against factor II or V) (Kuhlmann 2015)

Stenoses: A significant stenosis leads to a drop in flow, recirculation, venous congestion syndrome and thrombosis.

Causes of stenosis may include:

- shear stress due to turbulent blood flow

- Vein elongation (leads to pressure stenosis)

Before a thrombosis due to a stenosis occurs, the following warnings are given:

- Reduced blood flow in the shunt

- increased recirculation

- an increased outlet pressure is found in the venous hose system (Kuhlmann 2015)

The shunt is preferably applied to the non-dominant hand - left for right-handers and right for left-handers (Keller 2010).

The vein (predominantly the cephalic vein) is anastomosized with the radial artery (Kasper 2015).

Before the shunt can be used, the so-called "maturation process" must be awaited, which takes about 3 - 6 weeks. This process can be accelerated with training. For this purpose, the forearm muscles are strengthened by kneading elastic balls for about 5 minutes several times a day (Keller 2010).

A well developed Cimino- Brescia shunt can sometimes be used for up to 20 years (Kuhlmann 2015).

No more blood samples may be taken from the affected arm before the shunt is placed (Herold 2020).

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2. Geberth S et al (2011) Practice of dialysis according to the guidelines NKF KDOQITM, KDIGO, EDTA, DGfN. Springer Publishing House 16
3. Hepp W et al (2016) Dialysis shunts: Basics - Surgery - Complications. Steinkopff Publisher 53
4. Herold G et al (2020) Internal medicine. Herold Publishing House 644
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7. Keller C K et al (2010) Practice of nephrology. Springer Publishing House 234
8. Kuhlmann U et al (2015) Nephrology: Pathophysiology - Clinic - Kidney replacement procedure. Thieme Publishing House 692