Kenneth C. Appell, MD

"The American Surgeon" Recognizes Kenneth Appell's Invention of the AV Fistula

2009-06-19T14:14:00.004-04:00

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As recounted in this Web site's very first post, on August 2, 2008, Dr. Appell was contacted in the summer of 2004 by José Ramón Polo, head of vascular surgery at Marañón Hospital in Madrid, Spain. Dr. Polo's conviction that credit for the AVF had been hijacked was so strong that he felt driven to help set the historical record straight, and toward that end was working on an article he hoped to publish in a widely-circulated English-language medical journal. The resulting article was finally published in the February 2007 issue of The American Surgeon (Vol. 72, No. 2).

It must be noted that due to an error in transcription, the dates given in this article for the first and second fistulas are incorrect, and unfortunately this mistake was not caught in proofing. Instead of the date of February 1965 for the first attempted AVF and March 1965 for the second, the first attempt in fact occurred in February 1963 and the second in March 1964.

Following is the text of Ramón Polo's article:

Historical Vignette: Kenneth Charles Appell, M.D.: The Surgeon Who Performed the First Radiocephalic Fistulas for Hemodialysis

José R. Polo, M.D., Ph.D.
Department of Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain

Radiocephalic fistula for hemodialysis is the most effective vascular access since it was developed at the Bronx Veteran's Administration Hospital in New York by Kenneth Charles Appell in February 1965. The first fourteen cases were published in a classical paper (N Engl J Med 1966; 275:1089-1092). Some aspects of the biography of Dr. Appell, together with the history of the development of radiocephalic fistula are described in this historical communication. Dr. Appell, age 82, is currently living in New York's Hudson Valley.

Very few surgical operations are commonly associated with the name of the surgeon who designed them (the Nissen funduplication, the Halstead mastectomy, the Whipple pancreatoectomy, and so on). Generally speaking, all these operations remained practically unchanged with time and continue to be very successful. The purpose of this brief paper is to remind the medical community of the surgeon who designed and performed the first radiocephalic fistulas for dialysis, Kenneth Charles Appell, whose name was unfairly forgotten and never associated with the surgical technique that he designed in the 1960s.

Kenneth Charles Appell was born in 1923 and attended Manhattan College in New York City. He enlisted in the U.S. Navy in 1942, serving in the South Pacific during the Second World War. After coming back from the Pacific, he completed his college education and then matriculated at Georgetown University Medical School in Washington, D.C.

Afterward, he performed his training in general surgery at Saint Vincent's Hospital in New York City and the Veteran's Administration Hospital (V.A.) in Brooklyn, New York. He was mainly interested in oncologic and vascular surgery. He performed his first repair of an aortic aneurysm in 1957.

Hemodialysis was performed at the Bronx V.A. Hospital in 1960 under the care of internists Michael J. Brescia, M.D., and James E. Cimino, M.D. Dr. Appell performed the Scribner shunts that were then used as vascular access for dialysis. Various alternatives were tried to avoid the many complications associated with the external shunts, including the interposition of a small 4-mm-diameter Dacron segment that was usually subject to thrombosis. Direct anastomosis of the vessels was avoided because traumatic arteriovenous fistulas were often associated with cardiac failure. In 1961, Dr. Appell became aware of a paper from the Mayo Clinic describing a 10-year study in which arteriovenous fistulas were used to increase bone growth in children. Dr. Appell was convinced that a small radiocephalic fistula would be well tolerated.

The first fistula was performed in February 1965. It thrombosed, probably because of the small diameter of the vein used. The second fistula was performed in March 1965, and the patient was dialyzed for a long time by puncturing the dilated vein without any problem. One hundred forty-three procedures performed at the Bronx V.A. Hospital were presented by Dr. Appell in 1989 at the first meeting on Vascular Access for Hemodialysis (Phoenix, Arizona) organized by Ohio University. The main technical aspects currently used for the procedure were then described: use of microsurgical instruments and magnifying lenses, and fine suture. The results of the first 14 patients with radiocephalic fistulas created for hemodialysis were published in a classic paper in the New England Journal of Medicine in 1966. Since then, the procedure was generally referred to as the Brescia-Cimino fistula.

Dr. Appell left academic surgery in 1970 and continued performing general surgery in New York's Hudson Valley until he retired. Dr. Appell, currently 82 years old, continues to live in that area with his charming wife, Marcella. I believe that all surgeons, nephrologists, nurses involved in hemodialysis, and dialysis patients are indebted to Dr. Appell for the development of this simple and successful operation.

Kenneth Appell's 2007 Speech About His Invention of the AV fistula

2009-05-25T12:56:00.008-04:00

On November 14, 2007, Dr. Appell was recognized for his historic development of the AV fistula at the New York City meeting of the Vascular Access Society of the Americas at the Veith Symposium. In addition to being presented with an award, he was invited to give an address describing the circumstances surrounding the AVF's invention, and thoughts and observations regarding the procedure. Following is the text of his presentation:

The Concept of an A-V Fistula for Vascular Access

I would like to present to you some of the history of hemodialysis and vascular access surgery as I lived it. In 1960 the administration at the Bronx Veterans Administration Hospital decided to establish a hemodialysis clinic. A clinic in those days was an institution that did one dialysis per week. In New York City there were four such clinics: BVAH (where I was associated), Mount Sinai, Bellevue and DownState in Brooklyn.

Our dialysis machine at the BVAH was the Kolff twin coil and the team consisted of two internists, a surgeon, a lab technician and a nurse. The problem then, as it is now, was one of vascular access. The technique then employed was the use of the Scribner shunt. This shunt was developed at the University of Washington in Seattle by Quinton, Dillard and Scribner. Quinton was an engineer, Dillard a surgeon, and Scribner an internist.

The shunt in essence was a controlled AV fistula, controlled essentially by the diameter of the Teflon catheter and the connecting tubing. Such a controlled fistula is in contrast to a native AV fistula which is usually traumatic and involves large vessels. The literature at the time was replete with the adverse effects of native fistulas. They were to be avoided.

The Scribner shunt had many problems, including bleeding, infection, erosion, clotting, and the need for the patient to have a bulky dressing in order to maintain some sense of sterility.

In 1961, an article appeared in the Proceedings of the Mayo Clinic which described a ten-year study in which a group of children with a shortened limb (usually secondary to polio) were subjected to the construction of a native AV fistula in the hope that the increase in blood flow would cause a corresponding increase in limb growth. Their fistula was one half-inch in diameter and connected the superficial femoral artery with the deep femoral vein. A slight increase in heart size and heart rate and the typical murmur of an AV fistula developed in all of the children, but they appeared to tolerate these changes and these changes were reversible with closure of the fistula.

This was the first time I had found evidence in the literature which would correlate the effects of fistula size and vessels involved with the patient’s response. The consensus at the time was that all AV fistulas were to be avoided because of their adverse effects and difficulty to repair.

I reasoned that if such a large fistula involving major vessels, albeit in children, could be tolerated, would not a smaller fistula in smaller vessels be tolerated in adults.

This was my epiphany.

In February 1963 I attempted my first case. Vascular surgical instruments for this type of microsurgery were not available, so I went to the Department of Ophthalmology at BVAH and borrowed their equipment, including a loop magnifier. The first patient happened to be a very poor candidate for an AV fistula as he had very poor veins. I was, however, able to construct a side-to-side anastomosis between that small vein that crosses obliquely across the volar surface of the wrist and the radial artery. I estimated that the fistula was approximately two millimeters in diameter. I had hoped that with the increase in venous pressure additional veins would open up but this did not happen and it never does. This first case therefore was a failure as a means of vascular access but I was encouraged, because having never worked with vessels of this size before, I was able to construct a patent AV fistula.

My next case was in March 1963 and was a much better candidate. I was able to create a side-to-side radial-cephalic fistula which worked perfectly. With this success I gradually changed from Scribner shunts to peripheral AV fistulas.

My technique changed little over the years. The patient was prepped with alcohol and Betadine and the anesthesia employed was 2-percent Xylocine. A four-centimeter transverse incision was made over the anteria-lateral aspect of the wrist just proximal to the radial styloid. The subcutaneous tissue was not incised, as I felt this would offer some protection to the overlying skin and the underlying anastomosis. Disection then continued medially down to the antibrachial fascia, which was incised longitudinally. The artery was freed up over a distance that would allow easy displacement of the vessel from its bed without kinking. This latter consideration is most important in mobilizing both the artery and the vein. Vascular loops of 2-0 black silk were used to control the vessel. Disection then continued under the subcutaneous tissue at the level of the fascia to the cephalic vein located laterally in the subcutaneous tissue. The vein was likewise freed-up over a longer length than the artery but again avoiding any kinking or obstruction. At this point the patient was heparinized with 5,000 units of sodium heparin, and dilute heparin was subsequently used as an irrigating fluid. With both vessels controlled with tapes, they were brought together under the subcutaneous tissue. The tapes are used to both control position and to control blood flow; by increasing tension on the tapes, bleeding can be adequately controlled. I tried to avoid vascular clamps because I felt they were too traumatic, and besides they cluttered the field. An incision was then made with the tip of a No. 11 scalpel, and this was then enlarged to about five to six millimeters with a curved iris spring scissor. A side-to-side anastomosis was made in an over-and-over fashion with 6-0 or 7-0 silk (silk was the only available suture material at the time and it subsequently was replaced with Proline). With completion of the anastomosis, the opening should be about five millimeters. When mature, this would give a flow rate of 250 to 350 ccs per minute. The tapes are removed sequentially, first the venous side, then the distal artery, and finally the proximal artery.

A definite thrill should be palpable and venous distension may be observed. If a thrill is not present you must assume an error in technique and it should be corrected. In my experience no fistula has failed to function if a thrill was present. Careful inspection of all vessels to assure that there is no kinking or obstruction should be done. The skin was closed with interrupted nylon sutures.

Postoperatively heparin is not continued. The hand is elevated on a pillow until edema which usually occurs has subsided. Pressure bandages and elastic bandages are to be avoided.

A well constructed AV fistula can be used almost immediately, but it is better to allow a four- to six-week period for maturation to occur as this will make needling easier and give better flow.

The first ten years of access surgery at the BVAH involved 112 patients and 143 procedures. A total of 100 side-to- side and 43 end-to-side AV fistulas were constructed. One can expect a long life from a properly constructed and maintained AV fistula. For example, in 1965 Dr. Scribner sent me a patient in whom I was able to construct a peripheral fistula. In 1987, he presented that patient at a conference on vascular access in Phoenix, Arizona, and at that time the patient had had over 20 years of dialysis treatment with the same fistula. A life span of 20 to 30 years is not unheard of.

Every surgical procedure has its complications, and the peripheral AV fistula is no exception. Fortunately, they are not too common and are usually correctable without difficulty.

Aneurysms, both true and false, occur. The latter are usually the result of faulty needle technique. False aneurysms should be repaired, as they can obstruct venous drainage. True aneurysms occur at the A-V site and need not necessarily be repaired. I have never seen a peripheral aneurysm rupture. If they become unsightly or symptomatic, they should be excised and a new anastomosis constructed at a more proximal level.

Congestive heart failure is a rare complication. I preferred to treat this problem by exposing the fistula site and narrowing the stoma with well placed sutures.

The blue thumb or sore swollen hand syndrome is due to venous hypertension and should be treated by ligating any enlarged vein distal to the fistula. More frequently, however, venous hypertension is secondary to more proximal narrowing or obstruction. A brachial angiogram may be necessary to define the obstruction. Adequate bypass, e.g. venous graft or side-to-side venous anastomosis, may be necessary. Occasionally thrombectomy may be successful.

I did not encounter the “steel” phenomenon. Perhaps because the patients I encountered were younger than those you see today. I always preoperatively ascertained the competence of the ulnar artery flow by the Allen Test. I would not insert an AV fistula if it were felt that the ulnar artery was incapable of providing adequate peripheral circulation.

I would like to emphasize that the success of a vascular access program depends largely on the physician who first anticipates the subsequent need of his patient for dialysis. The venous pattern of the non-dominate arm (if available) should be protected absolutely from all attempts at bloodletting, I-Vs and I-V medication.

The concept of a peripheral AV fistula as a means for repeated access to the circulation is a concept that has established itself. It should be considered in any long-term therapy program requiring such circulatory access.

In conclusion, let me leave you with the logo of the hemodialysis unit at the University of Oklahoma -- namely, “Fistula First.”

Bronx V.A. Hospital Chief of Surgery Andrew James McElhinney Discusses Kenneth Appell's Invention of the A.V. Fistula

2009-04-22T11:02:00.005-04:00

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Now semi-retired, Dr. McElhinney graciously granted an interview to this Web site on April 14, 2009 at his home in Pelham, New York, just north of the Bronx. The transcript of that interview follows.

“I’m Jim McElhinney, retired surgeon. I was Chief of Surgery at the Bronx V.A. from 1975 to 2003, and I first met Ken Appell when I was a resident, a surgical resident in the V.A., from '59 to '62 and through '63. And so I was there when he developed the arteriovenous fistula for patients on hemodialysis. Prior to that time, the patients who were in kidney failure and needed dialysis had to have their dialysis run through catheters put into the blood vessels in their arms or wherever to dialyze them. The Scribner shunt was the first shunt implanted which implanted catheters in the vessels. And then Dr. Appell conceived the idea of making an arteriovenous fistula -- an anasthemosis or connection between an artery and a vein in the wrist area. This enabled the blood supply to be easily accessed with a needle and then removed after the dialysis was performed.

As a result of that, the Bronx V.A. had the largest hemodialysis unit in the New York area -- because of the development of the AV fistula by Dr. Appell. He worked with Drs. Brescia and Cimino, the nephrologists, and it's often called the "Brescia-Cimino shunt." But it really should be called the "Appell shunt," because he was the one that manufactured it. He had been interested, before doing the shunt for dialysis, in perhaps using a fistula down in the foot area, ankle area to increase flow through the blood vessels that were being reconstructed for people who had inadequate blood supply to their legs. And so he was familiar with the concept of anasthemosing an artery and a vein together. He didn't pursue that any further, as far as I know, but then he went on and did many different things, excelled in many different areas of surgery, including vascular surgery. And I was there when he started the fistula, and after he left I took up the production of the AV fistulas and I had several people on my staff who later developed -- didn't develop but continued to work on the same principle that Dr. Appell had pioneered and developed.

Q: Great, and what was your understanding of the timeline? What was the nature of Dr. Appell's association with Drs. Cimino and Brescia, and how is it that it became confused subsequently as to who was responsible?

Well, they were the senior authors on the paper, so I think that's how it became known as the Brescia-Cimino shunt. In Europe, some of the surgeons told me, that in Europe it was called the "Bronx shunt" because it was developed at the Bronx VA. But I had always reminded people in different lectures that I gave around the country that it was Dr. Appell who really developed the shunt that made all of hemodialysis so much more practical and expanded it to so many people with kidney failure. He was recognized at several of the vascular meetings as the developer of the shunt -- or the fistula, I should call it, really. And it's just taken for granted today that unfortunately not many people realize that he was the one who was the developer of it.

Q: I'm curious as to when you first learned about the idea of the AV fistula, the idea and the actual success of it, and what you reaction was.

Well, that was when I was a surgical resident, first in general surgery and then in cardio-thoracic surgery. And I used to sometimes assist and other times just watch Dr. Appell -- because it's a miniature incision in the wrist, and you can't really have too many people working at the same time. But I used to watch to see how he was doing it and what the techniques were and what the problems were associated with the creation of the fistula. And so the people at the Bronx VA after Dr. Appell left continued on and also became very proficient in it -- as have people all around the world.

Unfortunately, some people look for a simple answer to the problem of kidney failure, and put in a synthetic graft in the arm or anyplace in the body to make an easier graft from the, say the wrist or even the upper arm, from an artery to a vein. The problem with using those synthetic grafts is that their life is quite limited and it then creates other problems. Even though it makes it simpler to do initially, the much better solution is the autogenous tissue of the AV fistula.

Q: So you would agree with the philosophy of "fistula first," with the native fistula, as opposed to the other alternatives that have been developed?

Absolutely, and also to persist in using the fistula, because sometimes it's very easy to just say, "Oh, we'll stick in a graft, and that's quicker and easier," but -- it's quicker and easier but it's not as good, and not as lasting, and it poses a lot of its own problems.

Q: Very good. One last question. Were you friendly with Dr. Appell at the time? Did you socialize at all? What did you think of him as a person?

Oh, he was a wonderful man. He was a young attending in surgery and I was a resident -- first chief resident in general surgery and then in cardio-thoracic surgery. And so we did work together as resident and attending on many cases, and he was an excellent surgeon -- all-around surgeon, not just in fistulas and vascular surgery but in all areas of surgery.

Q: Well, he always said it was a pleasure to work with you, so I thank you for your time.

Oh, you're quite welcome!"

AVF Inventor Kenneth Appell Discusses Fistula's Limitations

2009-03-03T09:55:00.016-05:00

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Dr. Kenneth Appell remains engaged in current medical developments and thinking, and recently had an interesting exchange with Long Island, NY nephrologist Simon E. Prince, who industriously and informatively puts out The Nephrology Blog. This past February 25, Dr. Prince added the following post:

Vascular Access Controversies

The Renal Business Today website has an interesting 'roundtable' discussion on Vascular access today.

This follows the excellent thought-provoking recent videoblog of Dr Berns: AV Access and Fistula First? This is then followed by some excellent comments from the nephrology community.

I support Fistula First. But also, I believe an AVF is not always appropriate. I believe the rhetoric can be toned down a notch. Dialysis units are incentivized to have a higher %AVF, and it although it is undoubetdly usually the best option... it is not always the best option for each individual patient.

Some examples where Fistula First may not be best:

1) Potentially reversible disease. There are instances of acute renal failure which requires dialysis, but recovery is anticipated... or at least possible.

2) Poor life expectancy. Some of our patients have such terrible co-morbidities that AVFs are not the appropriate.

3) Short term use of dialysis/ ultrafiltration. Such as for someone with congestive heart failure who requires atypical treatments based upon complimenting medical therapy.

4) Terrible vascular anatomy. Sometimes it is not feasible to attempt an AVF... although, there are many talented Vascular surgeons who can usually succeed in even the most difficult cases.

5) Some patients show up at the hospitals with stage 5 CKD and need RRT and it is logistically difficult to arrange an AVF prior to discharge (these patients should have "Fistual Second")

In a perfect world, no one can argue fistula first... unfortunately, circumstances (especially within the patient population we deal with) are not always ideal.

Dr. Appell commented on March 2:

As the originator of the peripheral A-V fistula, I agree in general with your comments.

The peripheral A-V fistula is the best method for chronic vascular access. We can anticipate 10 to 20 to 30 years or more of use from an A-V fistula.

However, there are instances where an A-V fistula would not be indicated.

In patients with multiple or severe co-morbidity that may be life-threatening it would not be indicated. Other means are available for dialysis. After all, an A-V fistula requires an operative procedure.

The A-V fistula is designed for long-term use. Patients requiring short-term dialysis are best treated by central lines.

The question of closure of an A-V fistula following a successful kidney transplant would depend upon the particular patient. If the fistula is not unsightly we should consider keeping it as a backup. Fistulas are well tolerated and do not detract from the transplant.

In general, as in all good medicine, the therapy should be designed to fit the patient and not vice-versa.

Dr. Prince graciously responded that same afternoon:

Such a distinguished guest... I am honored, Dr. Appell. Thank you for your contribution to the field of Nephrology… as well as for taking the time to comment here.

AV Fistula Inventor Kenneth Appell Salutes Hemodyalisis Inventor Willem Kolff

2009-02-12T16:26:00.021-05:00

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One of the great medical innovators of the past century died yesterday in Philadelphia, three days short of his 98th birthday. More recently known also as one of the designers of the artificial heart implanted in Dr. Barney Clark in 1982, Dr. Kolff was born in the Netherlands and began his attempts to design an artificial kidney 70 years ago during the Nazi occupation of his country. He moved to the U.S. in 1950, and did more of his seminal work at the Cleveland Clinic and the University of Utah.

Upon learning of Dr. Kolff's passing, his fellow kidney dialysis pioneer Kenneth Charles Appell commented, "A great man, whose contribution was necessary to the whole concept of hemodialysis. There had been work done on artificial kidneys before Kolff came along, but he refined the work and translated it into a useable machine that became the basis for all the equipment in use today.

Unfortunately, I never got to meet him, but from a personal standpoint I'm grateful -- without Willem Kolff's machines there wouldn't have been any reason for my own work, no way of using the AV fistula. And -- age 98, eh? Good for him!"

What Is the AV Fistula & Why Was It Revolutionary?

2009-01-19T10:11:00.001-05:00

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The arteriovenous fistula invented in 1963 by general surgeon Kenneth Charles Appell at the Bronx Veterans Administration Hospital is considered by many experts to be one of the top medical breakthroughs of the 20th century, an advance in kidney dialysis that in the 46 years since has saved and improved the quality of many, many millions of lives around the world.

Basically, an AV fistula is a little tunnel created between an artery (hence “arterio”) and a vein (“venous”). In some cases it may be due to disease or birth defect, but Dr. Appell’s landmark achievement was to create such a connection surgically so as to provide the best vascular access possible. That’s absolutely critical for effectively dialyzing kidney patients – it allows blood to be more effectively pulled from the vein for filtering and purifying in a dialysis machine, then returned to the vein using the blood pressure from the connected artery. It’s usually applied to a patient’s arm -- generally the forearm -- but can also be elsewhere (for example, the leg or shoulder); it requires an operation taking an hour or two, followed by several weeks of healing before it can actually be used in dialysis. Dr. Appell’s original procedure was actually a type of AV fistula called a radial-cephalic fistula, between the radial artery and the cephalic vein near the wrist.

Before Dr. Appell conceived the AV fistula while working at New York’s Bronx Veterans Administration Hospital nephrology unit, hemodialysis was a painstaking and downright painful procedure with a high failure rate. The method used was the Scribner shunt, invented by a University of Washington team and named after its internist member, Belding Scribner, in 1960 and used in conjunction with the Kolff artificial kidney, invented in the early 1940s by Willem Kolff in the Netherlands. But the Scribner shunt used tubing and a catheter (Dr. Appell’s innovation was “native,” using the patient’s own blood vessels), and so it had many problems, including bleeding, infection, erosion, clotting, and the need for the patient to have a bulky dressing in order to maintain sterility.

Today there are more than 300,000 end-stage renal patients being dialyzed around the world. Referring to them in a recent interview, Lawrence Spergel, a physician working with an organization called Fistula First, asserted that the AV fistula “is truly their lifeline; without an adequate vascular access they cannot survive.”

However, a growing problem has arisen in recent years (and one that’s the reason for the existence of Fistula First, which works with the U.S. Department of Health and Human Services): that moving away from the “native fistula” invented by Dr. Appell and – ironically – back toward the concept of the Scribner shunt. Too many doctors have been convinced to rely on commercially profitable arteriovenous grafts and venous catheters made of plastic; unlike these, the native AV fistula is non-patentable (so no big bucks, sorry!). Though these methods provide more profits to the companies that have patented them, they’re far less wonderful for patients: they’re shorter-lived, need more repairs, have higher rates of infections, and cause more hospital stays.

Bottom line: Kenneth Appell’s original invention is still the gold standard in kidney dialysis.

An Interview with Dr. Appell: Teens & Young Adulthood in New York City

2008-12-31T21:20:00.000-05:00

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In this 10 1/2-minute interview taped in August 2008, Kenneth Appell discusses his teenage friendships, crushes, weightlifting, and the beginnings of his interest in medicine. Also covered is his matriculation in Manhattan College and his first job, at the main branch of the New York Public Library. (For pictures of his onetime house and neighborhood, as well as Manhattan College and the New York Public Library, see the accompanying photo gallery.)

An Interview with Dr. Appell: Boyhood in New York City

2008-10-29T07:27:00.003-04:00

Ken Appell discusses his early childhood in Queens, New York; this 8 1/2-minute segment was taped in August 2008. (Transcript follows; for pictures of his house and neighborhood, see the accompanying photo gallery.)

"I was born March 23rd, 1923 in New York City, Manhattan – one of the unusual [cases] when somebody was born in Manhattan, not immigrated there. We lived on 77th Street off York Avenue, and my family – including my father and my mother and my sister – subsequently moved to Queens, where my dad bought a house on 42nd Street in Long Island City, and we lived there for many years. My mother subsequently died while we lived there. I was about five years old, I guess, when she passed away. And the rest of my childhood was influenced by my grandmother, who lived next door, and I was brought up essentially under her direction.

My family was, my father was of German extraction – Bavarian – and my mother was Czechoslovak, from Bohemia. I went to grammar school P.S. 6 in Astoria, which is still there, the school is still there. And it was a school that you walked to – it was a walk of about, oh, about three city blocks. Which was fine in the spring and summer but in the wintertime it was plowing through a lot of snow (chuckles). I graduated from P.S. 6 after falling off a gate and breaking my arm, and subsequently went to Bryant High School, which at that time was located in Long Island City. And Bryant was an interesting school, in the sense that the students came from a wide area in Queens, and Brooklyn, even. The school subsequently moved to a new building in Queens. While they were building that school, some of the students from Long Island City High School were switched over to a school in Sunnyside which was sort of an annex of Bryant High School. And that was an interesting experience because walking from my house on 25th Avenue and 42nd Street in Astoria to Sunnyside was a walk of approximately, maybe, 1 1/2 to two miles. And in order to get there, I improvised a shortcut through the Long Island City freight yards. I would get to school by hopping across the tracks and getting to school that way.

My dad worked for the Railway Express Agency,* he drove an electric truck in Manhattan. He did that for years, and he drove one of the last electric trucks the Railway Express Agency had in Manhattan. So my association with my father was, ah, sort of distant. He was kind of a quiet man, he didn’t socialize too much – although he did like to have some friends in for a drink once in a while, you know, he enjoyed that.

My upbringing was essentially under the aegis of my grandmother, who did all the cooking. And we went from my apartment to her apartment, which was next door – we lived in two family houses there. I would take my meals there with my grandmother, and she was the one that made me go to church with her every Sunday (chuckles) and every holiday, and on Friday I had to eat fish. She was a devout Catholic, and an absolute world-reknowned cook! (chuckles) I can remember her manufacturing a soup for the family and starting off with an empty bottle of ketchup, which she rinsed out with water, put it in the pot, and managed to get various and sundry ingredients from the refrigerator and come up with this delicious soup that everybody enjoyed. She was a wonderful person, and I adored her. She was a woman who managed to do a lot of things with very little income.

Uh, she used to like to go to a Bohemian church over in New York City -- I think it was in the 60s between 1st and 2nd Avenue, I think it was. And I remember her taking me there on Sundays many times to listen to, uh, short plays and things that were done in Czechoslovak. And of course I didn’t understand that much Czechoslovak. The only Czech I understood was what my grandmother taught me, and she didn’t teach me enough to follow the script of a play. But I would spend a Sunday over there, and we would have dinner over there – a typical Czechoslovak meal a lot of times, with what they call knedlíky** and zeli*** and pork, you know. That was very pleasant. She also used to take me to soccer games. At that time, a trolley car ran down Steinway Avenue, which was the main drag in Astoria, and at the end of the road, at Steinway Avenue, there was a soccer field. And of course the ethnic, uh, mid-European people in the area all gathered there on a Sunday, and they would play soccer. I didn’t know what soccer was (chuckles) from anything, but I’d watch them running up and down the field kicking this ball, and that was a pleasant way of spending a Sunday afternoon, too.

As far as my high school was concerned, uh, I wasn’t particularly interested in anything except maybe biology was a little more fascinating to me than anything else. I always felt rather – I didn’t feel that I was a real “brain,” as you would call it, you know. Although I did get good marks, I got good marks because I’d spend time. I had this quality of being very – if I started to do something, I really stuck to it, and I worked at it, and so I spent a lot of effort that way. But I guess biology was one of the more interesting subjects that I had."

* An important cargo railroad (1917-1975).
** dumplings (bread or potatoe)
*** sauerkraut

The Life & Career of Kenneth Charles Appell, M.D.: A Quick Biography

2008-09-19T17:48:00.001-04:00

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On March 23, 1923, Kenneth Appell was born in New York City on Manhattan’s Upper East Side (East 77th Street, off York Avenue); after the death of his mother, his father moved with Ken and his sister Florence into a brick two-bedroom house in Astoria, Queens (see gallery).

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In 1940-42, he attended Manhattan College in the Bronx, New York City, but his undergrad career was interrupted in 1942-46 by service in the U.S. Navy. He trained and was stationed at J.V. Newland Field at Baylor University in Waco, Texas; Lambert Field in St. Louis, Missouri; and air bases in Jacksonville and Pensacola, Florida. He subsequently flew missions in the Pacific theater of World War II.

The war over, in 1946-47 Ken Appell completed studies and graduated (second in his class) from Manhattan College. In 1947 he continued on to Georgetown University School of Medicine in Washington, DC, graduating in 1951 with that year’s Gold Medal in Pathology. During medical school, he returned to Astoria to marry fiancée Marcella Varmuza, who then moved to DC with him.

Right out of medical school, the newly minted physician did a 1951-52 rotating internship, at St. Vincent’s Hospital in New York City. That was followed in 1951-56 by a general surgery residence, then a year as research associate, at Brooklyn VA Hospital in Bay Ridge.

After being certified in 1958 as a diplomate of the ABS (American Board of Surgery), the following year Dr. Appell served as surgical coordinator at Grasslands Hospital in the Westchester County (New York) town of Valhalla. A year after that, he and his wife moved to Westchester, to the city of Port Chester.

Following two years as attending surgeon at the Bronx VA Medical Center, in 1961-62, through 1965 he became general surgery section chief and research associate at this same hospital. It was here, in 1963, that Kenneth Appell made medical history with his invention of the AV fistula (aka the radiocephalic fistula). During this period he also taught as a clinical instructor at Albert Einstein College of Medicine.

The Sixties were a busy decade indeed for this distinguished surgeon. Overlapping with his tenure at the Bronx V.A., in 1962-69 he was also visiting surgeon at Harlem Hospital in upper Manhattan, and in 1963-69 served as Chief of Surgery at Calvary Hospital in the Bronx. This non-profit insitutition affiliated with the Roman Catholic Archdiocese of New York is the United States’ only fully accredited specialty hospital providing acute and palliative care exclusively for advanced cancer patients. On top of all the above, during his last year Dr. Appell was also president of Calvary's board of directors. It was also during this period, in 1968, that he received a Veterans’ Administration commendation for advances in the field of hemodialysis -- primarily for his creation of the AV fistula.

In 1969, Dr. Appell's life changed significantly once again. He spent part of that year as a consultant in vascular sugery at the Holy Name Hospital in Teaneck, New Jersey and consultant in surgery at St. Joseph’s Hospital in the Westchester city of Yonkers. But that same year, he moved with his family (wife Marcy, son David, daughter Ann) to the part-rural/part-suburban town of Red Hook, 100 miles north of New York City in the Hudson Valley’s Dutchess County, and started practicing medicine at Northern Dutchess Hospital in nearby Rhinebeck. His first partner in practice was Dr. Bill Jameison, followed as of 1980 by Dr. Jim Wing.

Since 1969, Kenneth Appell has been an attending surgeon at Northern Dutchess, as well as Chief of Surgery for much of that time; in 1973 also became an attending surgeon at Rhinebeck’s Ferncliff Nursing Home. He continues at both institutions to this day, even in semi-retirement.

In more recent years, Kenneth Appell's invention of the AV fistula has finally begun to be somewhat better appreciated after years of unfair attribution to colleagues in the Bronx V.A.'s nephrology unit (it has sometimes, for example, been referred to as the Brescia-Cimino shunt). Landmarks in this process included a well received paper on the subject Dr. Appell delivered in 1988 at the Symposium on Vascular Access for Hemodialysis, held in Phoenix, Arizona. The pace has picked up a bit in the past three years, most notably in 2006 when José Ramón Polo, a distinguished surgeon based at Gregorio Marañón Hospital in Madrid, Spain, published a "historical vignette" article. "Kenneth Charles Appell, M.D.: The Surgeon Who Performed the First Radiocephalic Fistulas for Hemodialysis" appeared in the February issue of The American Surgeon (Vol. 72, No. 2). In November of last year, Dr. Appell presented keynote address at the tenth annual Veith Symposium on Vascular Access in New York City, and was awarded honory membership in the Vascular Access Society of the Americas.

For additional specifics on and images of Kenneth Charles Appell's life and career, please see the accompanying photo gallery.

Working with Dr. Kenneth Appell: An Interview with Nurse Jaime Dillenger

2008-08-18T15:24:00.002-04:00

In a five-minute interview taped in August 2008, operating room nurse Jaime Dillenger describes her professional association with Kenneth Appell, dating back to 1982 (transcript follows).

"My name is Jaime Dillenger; I worked with Dr. Appell for 20 years in the O.R. at Northern Dutchess Hospital. Dr. Appell was the best surgeon I have ever worked with in my entire life. And having worked in an O.R. for almost 30 years, I’ve worked with a lot of surgeons. He was a wonderful teacher. When I went to work in the O.R. I had no O.R. experience, and he taught me many, many different things. Um, he was very respectful with tissue and excellent with anatomy, and he was a great teacher, and I always loved working with him.

I started in the O.R. in 1982. I’d worked in the E.R., so I knew him from the Emergency Room when I was in nursing school. And then I worked from 1982 till 2000 in the OR itself. And, you know, he became like my father, and you know, like I said, he was wonderful to work with, he was kind to the staff. You always felt that no matter how bad your case was, he would get you through. Even if it was an emergency, you didn’t see him getting ruffled or yell at you because something wasn’t going right, you know what I mean? It was like, there was always a purpose: okay, this is not a good thing, but, okay, we’ll fix it. Whatever the situation was, you just knew you were safe, you know what I mean? He would take care of the situation and he would get you through it and everything would be okay. He didn’t lose his cool, he didn’t yell at you, he didn’t scream at you – at anybody – you know what I mean? It was, “okay, this is what we need to do, and we will do it.” You knew the seriousness of the situation but you would remain calm because he was calm. I’m sure inside we were all panic-stricken (laughs), but like I said, you remained calm because he was. You knew he knew what he was going to do next. [With some other surgeons] you can definitely see that, “this is bad and I’m really not sure what to do.” And even if he thought that, you didn’t know he was thinking, “ oh, boy, this is a sinking ship.” You never, ever had that feeling with him. I’ve worked with a lot of surgeons, and you don’t always have that feeling that it’s going to be okay, that we’re going to work this out and everything’s going to be fine. You don’t have that all the time.

[I also became friends with him and his wife outside work,] especially after I divorced and after my dad died. When I was building the house, they would go every Sunday after church to check on the progress of the house and see how things were going. He would come to work on Monday and he would say, “I was out to Kansas yesterday” – my house borders on Kansas Road – “Marcy and I went to Kansas after church!” (laughs)

I remember one night working through an aneurysm with him and Dr. Wing, like, all night. And we finished at, like, four or five o’clock in the morning. I went to take a shower and he went into the lounge on the couch. And then I went in afterwards and made coffee for him, and he’s laying on the couch with a blanket and a pillow… (chuckles)

It was just so enjoyable to work with him. He would do anything – and especially in later years, when he was not doing as much surgery but helping Dr. Wing more – you know, he’d come back in the room, he’d be mopping the floor, he’d be helping you make the bed, you know what I mean, he’d be sitting in the lounge. Like I said, he was just an absolute pleasure to work with. He really was."

James Wing, MD Talks About Partner and Mentor Kenneth Appell

2008-08-10T17:14:00.000-04:00

In this six-minute interview taped August 6, 2008 at his home in Rhinebeck, NY, general surgeon Jim Wing discusses his twenty-year partnership with Dr. Ken Appell. Following is the transcript of that interview:

My name is Jim Wing, and I’m a general surgeon in Rhinebeck, and I’ve been associated with Dr. Appell for the last 20 years. I remember – I’ll start from the beginning, before it was the beginning for me and my association with him. I had just finished my residency and was – actually, I was at a teaching hospital and I’d stayed there for a couple of years afterwards and I was looking for a place to go to work after that. My sister lived in Rhinebeck, which was the initial impetus to come up here. And I looked at who the surgeons were in town here, and Dr. Appell was one and Dr. Jameson was another one. So I inquired of both of them just what the availability of, or their interest in having a partner would be at that point. Dr. Appell was actually quite interested at the time, so it was quite lucky for me.

I’ll tell a small tale out of school, I guess. I don’t think I ever told Dr. Appell this, but I remember coming up here and I’m sure – or actually I know – he looked me up and I looked him up, and we checked each other out. And one of the things I noticed was, ah, he’s 65, I said, how much longer can he really practice at this point. So I’ll be going up there and I’m sure that at some point soon after that he’ll want to retire. Well, he’s still helping me to this day. As a matter of fact, he helped me just two days ago in the operating room, and he’s still an excellent surgeon, and I’m glad to have him with me in the operating room.

So anyway, I came up here, and he, as I said, I was just inquiring as to whether he had any space or was interested in a partner. He was quite interested at the time, and in fact after we met and talked a little bit the first time, and I came back a second time, he offered to have me come in as a partner with him. And it’s been the happiest association ever since then, for the past 20 years, because I came up in July of 1988 and it’s now July or August of 2008, so that’s 20 years ago, and it’s been a wonderful association.

When I was coming up here and just looking Dr. Appell up and checking him out, I found out that he in fact was the person involved in what came to be known as the Brescia-Cimino shunt and should have been known as the Appell shunt, which is a radiocephalic fistula for dialysis for patients who are having kidney problems. He in fact was the surgeon involved in that study and was the one who did the actual legwork and the surgical work involved in the study, which is now a classic fistula for patients who have renal failure. And it’s been around for a long time – I remember doing it as a resident. We don’t do them at this hospital up here anymore because we don’t have dialysis capability. But I know Dr. Appell when he first came up here would go down to Poughkeepsie and perform the shunt down there. And I did it a number of times in Long Island where I was a resident and afterwards attending for a short while.

So that was very eye-opening to me, to realize that I was coming up to work with somebody who really was quite famous, and to this day is quite famous for that. That this is one of the things that will go down in surgical history as a real milestone, and something to be looked back upon. Um, it’s really ground-breaking, because it allows patients who do have chronic renal failure to have dialysis, and it’s a very functional shunt. So I was quite thrilled and quite impressed to be able to join someone of such magnitude.

And, um, sometimes surgeons are not the, uh, easiest people to get along with. I mean, we become know for our egos, and just because of the nature of the work that we do it can be quite stressful. But I have to tell you that I’ve never worked with, um, someone who is, uh, such a gentleman, and (chokes up slightly) uh… That I mean in two ways… he is truly a gentleman in terms of, um, his interactions with other people, and he’s truly a gentle man. I think in 20 years I don’t think I ever saw him really lose his temper and really, uh, get angry at anybody to the extent that surgeons are known for. Certainly we all have our moments when things don’t go right for us, and I was involved in him in that, because the operating room is a stressful place. But, um, he never, never lost his temper. I mean, he was very even-keeled – there were moments when things would go, uh, hoary, and we would need, you know, some help or, uh, it just wasn’t a pleasant situation. But he was never unpleasant in any situation that I can recall.

So it’s been, like I said, for 20 years, it’s just been a wonderful, wonderful, uh, partnership. And, um, he’s been a great mentor for me – I mean, I had some experience, but I was still a young surgeon at that point, and I picked up and fine-tuned my own surgical abilities, you know, because I was able to work alongside Dr. Appell and watch the things that he did, and incorporate some of the things that he did in my own practice of surgery. So it’s really been a fruitful existence for me, a fruitful relationship, and I’ve gained and progressed in my own surgical knowledge and my own surgical abilities because of being with him. Um, and as I’ve said I’m happy to know he’s still, um, able to come in and assist me, uh, in the operating room now, because he’s still a quite excellent surgeon – and I really, I really say that from the bottom of my heart. And I’m happy to know him and to have had the pleasure of working with him for many, many years.

In Honor of Dr. Kenneth Charles Appell

2008-08-02T15:20:00.002-04:00

My name is David Paul Appell. I'm a writer and editor for a variety of national and international media, but the thing of which I'm the most proud is that my father is Kenneth Charles Appell, the surgeon who in early 1963 revolutionized hemodialysis, improving and saving countless lives, by inventing the arteriovenous fistula while he was on staff at New York's Bronx Veterans Administration Hospital. Though it was entirely his idea and initiative, because he modestly delayed publishing his own results, two other doctors, James Cimino and secondarily Michael Brescia, went ahead and published in the New England Journal of Medicine (misspelling Dr. Appell's name in the process). As a result, the AV fistula unfairly and inaccurately became known as the Cimino shunt, Cimino-Brescia shunt, or Cimino-Brescia fistula, and over the years my father's authorship was all but shunted aside.

Now, more than 40 years later, fortunately, the record has finally, slowly, started to be set straight. Most notably, Dr. Appell was contacted by Dr. José Ramón Polo, a surgeon at the prestigious Gregorio Marañón Hospital in Madrid, Spain, who back in 1988 had heard him speak on the AV fistula at a conference in Phoenix, Arizona. Dr. Polo felt that history had done my dad a grave injustice, and thankfully had the initiative, persistence and most importantly the good heart to set about helping to correct this. Through e-mail exchanges and a personal interview during my family's visit to Madrid in November 2004, Dr. Polo wrote up a "historical vignette" article entitled "Kenneth Charles Appell, M.D.: the surgeon who performed the first radiocephalic fistulas for hemodialysis ," which was published in the February 2006 issue of The American Surgeon (Vol. 72, No. 2). Then on November 14, 2007, Dr. Appell gave a very well received keynote address on the subject in New York City at the annual meeting of the Vascular Access Society of the Americas during the Veith Symposium.

Despite the above, I've realized that in all too many in-print and online sources, as well as in the minds of many patients and people in the medical field, Kenneth Appell's seminal contribution is still attributed to the onetime friends and colleagues who took credit for the AV fistula and allowed it to be misnamed for all these years. So with the help of the Internet and those people, like Dr. Polo, who have stood by him, I have created this extensively documented Web site both as a tribute to my father's distinguished medical career and to combat this misinformation, giving credit where it is so clearly due. Millions of patients around the world owe their lives and quality of life to a brilliant but very modest, self-effacing surgeon who was too much of a gentleman to fight for the honor he was due, and who has been the most wonderful father I could have ever asked for.

Going forward, I will be adding photos, video, and other documentation chronicling Dr. Appell's remarkable career. Please stay tuned.