Cimino brescia shunt

Author: Dr. med. S. Leah Schröder-Bergmann

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Last updated on: 29.10.2020

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Synonym(s)

Cimino- Brescia- Fistula; Cimino- Fistula; dialysis fistula; dialysis shunt; Radialis shunt

History
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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).

Definition
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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).

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

Pathophysiology
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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).

Complication(s)
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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)

Therapy
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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).

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

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

Literature
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  1. Burchardi H et al (2004) Intensive care medicine. Springer Publishing House 813
  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
  5. Kasper D L et al (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education 1823
  6. Kasper D L et al (2015) Harrison's Internal Medicine. Georg Thieme Publisher 2241
  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

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Last updated on: 29.10.2020