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 Sherene Shalhub
Anahita Dua
Susanna Shin
Editors

Hemodialysis Access
Fundamentals and
Advanced Management

123
Hemodialysis Access
Sherene Shalhub • Anahita Dua • Susanna Shin
Editors

Hemodialysis Access
Fundamentals and Advanced Management

with contributions from Shahram Aarabi

Editors
Sherene Shalhub Susanna Shin
Division of Vascular Surgery Division of Vascular Surgery
Department of Surgery Department of Surgery
The University of Washington The University of Washington
Seattle Seattle
Washington Washington
USA USA

Anahita Dua
Department of Surgery
Medical College of Wisconsin
Brookfield
Wisconsin
USA

ISBN 978-3-319-40059-4 ISBN 978-3-319-40061-7 (eBook)

DOI 10.1007/978-3-319-40061-7

Library of Congress Control Number: 2016955418

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
To our patients who inspire us every day with their strength, resilience,
and compassion.
Preface

This book is a labor of love for our patients who live with end-stage renal disease on a daily
basis. The concept was simple and born 2 years ago when I realized that surgeons in the early
years of practice need a comprehensive text to help them navigate the subtleties of care for this
patient population. Maintenance hemodialysis became a reality in 1960, and over two million
people worldwide currently receive treatment with dialysis to stay alive. Although the role of
the surgeon is not especially glamorous, creating a successful hemodialysis access offers a
lifeline for a patient with end-stage renal disease.
The book is designed to be a reference for the surgeons, interventionalists, nephrologists,
and other providers who care for patients with end-stage renal disease. We wanted to create a
multidisciplinary clinical perspective between the various specialties that care for the same
patient. By providing a holistic approach to the issues that impact the patients and their provid-
ers, it is our hope that this will improve patient care and outcomes.
With this in mind, we divided the book into sections. The first section places the issue of
maintenance dialysis in perspective by starting with the history of hemodialysis access high-
lighting the successes and failures that brought us to today. The current state of dialysis in the
United States is then addressed, and we asked our colleagues from Japan and Taiwan to give
us another point of view by sharing their own experiences. The section concludes with a dis-
cussion of the ethical issues surrounding dialysis, as the inception of formal medical ethics
began with the evolution of chronic hemodialysis. The second section addresses hemodialysis
access planning with a focus on timing, decision-making, perioperative evaluation, and anes-
thetic considerations. The third section focuses on the technical aspects, the “how to,” for
creating hemodialysis access. The fourth section addresses the advanced skill sets required to
address hemodialysis access dysfunction. The final section covers alternatives to hemodialysis
such as peritoneal dialysis and the criteria for renal transplantation. It also discusses home
hemodialysis, wearable hemodialysis devices, and the outpatient approach to hemodialysis
access.
We dedicate this book to those who have taken upon themselves the mission of caring for
end-stage renal disease patients. It is our sincere hope that you will find the contributions in
this book valuable to your practice.

Seattle, WA, USA Sherene Shalhub, MD, MPH

vii
Acknowledgments

We thank our esteemed authors who have thoughtfully contributed to this book by generously
sharing their personal expertise and knowledge. Special thanks to Dr. Gene Zierler for his sage
advice that guided us in the process of a book publication and to Molly J. Zaccardi, RVT, and
Bonnie Brown, RVT, who kindly contributed representative images from the vascular
laboratory.

ix
Contents

Part I Historical Perspectives and Current State of End Stage

Renal Disease and Hemodialysis

1 Historical Perspectives on Hemodialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Sherene Shalhub
2 The Natural History of Hemodialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Fionnuala C. Cormack
3 The Current State of Hemodialysis Access and Dialysis Access
Initiatives in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Matthew B. Rivara and Rajnish Mehrotra
4 Hemodialysis Access Outcomes and Quality Improvement
Initiatives in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Devin S. Zarkowsky and Philip P. Goodney
5 Coding and Billing for Hemodialysis Access Procedures
in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Sean P. Roddy
6 Vascular Access: Experiences in the Aged Japanese Society . . . . . . . . . . . . . . . . . 49
Sachiko Hirotani, Shinya Kaname, and Shinobu Gamou
7 Hemodialysis Access: Fundamentals and Advanced
Management, the Experience in Taiwan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Shang-Feng Yang, Kuo-Hua Lee, and Chih-Ching Lin
8 Ethical Issues in Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Thomas R. McCormick

Part II Hemodialysis Access Planning

9 Timing of Hemodialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Mark R. Nehler
10 Preoperative Considerations and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Ted Kohler
11 Strategies of Arteriovenous Dialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Bao-Ngoc Nguyen and Anton Sidawy
12 Anesthesia and Perioperative Management Considerations
for the Patients Undergoing Hemodialysis Access Procedures . . . . . . . . . . . . . . . . 99
Koichiro Nandate and Susanna Shin

xi
xii Contents

Part III Creating Hemodialysis Access

13 Hemodialysis Access Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Christopher R. Ingraham and Karim Valji
14 The Role of Routine Venography Prior to Fistula Creation . . . . . . . . . . . . . . . . . 119
Berry Fairchild and Ali Azizzadeh
15 Direct Anastomosis: Cephalic Vein Hemodialysis Access . . . . . . . . . . . . . . . . . . . 125
Rachel Heneghan and Niten Singh
16 Forearm Vein Transposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Jennifer L. Worsham, Charlie C. Cheng, Zulfiqar F. Cheema,
Grant T. Fankhauser, and Michael B. Silva Jr.
17 Brachiobasilic Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Sherene Shalhub
18 Hemodialysis Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Shawn M. Gage, Ehsan Benrashid, Linda M. Youngwirth,
and Jeffrey H. Lawson

Part IV Hemodialysis Access Use and Assessment

19 Current Hemodialysis Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Lynda K. Ball
20 Outpatient Surveillance at the Dialysis Center . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Suhail Ahmad
21 Detecting Pending Hemodialysis Access Failure:
The Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Felix Vladimir, Suhail Ahmad, and Sherene Shalhub
22 Point-of-Care Ultrasound for Creation and Maintenance
of Hemodialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Gale L. Tang
23 Duplex Examination of the Hemodialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . 199
R. Eugene Zierler
Part V Hemodialysis Access in Special Populations and Ethical Issues

24 Considerations in Pediatric Hemodialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . 219

Beatriz V. Leong, Sarah M. Wartman, and Vincent L. Rowe
25 Hemodialysis in the Morbidly Obese . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Marlin Wayne Causey and Niten Singh
26 Creating Hemodialysis Access in Intravenous Drug Users:
A Vascular Surgeon’s Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Nam T. Tran

Part VI Hemodialysis Access Dysfunction and Advanced Techniques

27 The Immature Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

Dean Klinger
28 Understanding Intimal Hyperplasia Biology in Hemodialysis Access . . . . . . . . . 245
Seth T. Purcell, Shruti Rao, and Ruth L. Bush
Contents xiii

29 Arterial Inflow Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

C. Ingraham, G. Johnson, S. Padia, and Sandeep Vaidya
30 Hemodialysis Outflow Vein Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Eduardo Rodriguez and Karl A. Illig
31 Central Venous Stenosis and Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Andrew E. Leake and Ellen D. Dillavou
32 The Hemodialysis Reliable Outflow (HeRO) Graft . . . . . . . . . . . . . . . . . . . . . . . . 273
Shawn Gage, David Ranney, and Jeffrey Lawson
33 Hemodialysis Access: Fundamentals and Advanced Management . . . . . . . . . . . 281
April Rodriguez and Sherene Shalhub
34 The Infected Hemodialysis Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Animesh Rathore and Audra A. Duncan
35 The Thrombosed Hemodialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Edward Caldwell and George H. Meier
36 Understanding Hemodialysis Access Recirculation . . . . . . . . . . . . . . . . . . . . . . . . 303
Susanna H. Shin
37 Dialysis Access-Related Steal Syndrome and Neuropathy . . . . . . . . . . . . . . . . . . 307
Sung Wan Ham, Sukgu M. Ham, and Steve Katz
38 Cardiopulmonary Complications of Hemodialysis Access . . . . . . . . . . . . . . . . . . 315
Mariel Rivero and Linda M. Harris

Part VII Hemodialysis Alternatives

39 Renal Transplant Referral and Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

Lena Sibulesky, Priyanka Govindan, and Ramasamy Bakthavatsalam
40 Peritoneal Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Jared Kray, and W. Kirt Nichols
41 Home Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Brent W. Miller
42 Portable and Wearable Dialysis Devices for the Treatment
of Patients with End-Stage Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Cheong J. Lee and Peter J. Rossi
43 The Outpatient Dialysis Access Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Deepak Nair

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Abbreviations

ACR American College of Radiology

ACS-NSQIP American College of Surgeons National Surgical Quality Improvement
Program
AIUM American Institute for Ultrasound in Medicine
AVF Arteriovenous fistula
AVG Arteriovenous graft
BFR Blood flow rate
CAPD Continuous ambulatory peritoneal dialysis
CDUS Color Doppler ultrasonography
CKD Chronic renal disease
CMS Centers for Medicare and Medicaid Services
CPT Current Procedural Terminology
CQI Continuous quality improvement
CRBSI Catheter-related blood stream infections
CVC Central venous catheter
DAC Outpatient dialysis access center
DCD Donation after circulatory death
DOQI Dialysis Outcomes Quality Initiative
EDV End diastolic velocity
FFCL Fistula First Catheter Last
FFI Fistula First Initiative
JSDT Japanese Society for Dialysis Therapy
KDOQI Kidney Disease Outcomes Quality Initiative
KDPI Kidney Donor Profile Index
MAC Monitored anesthesia care and sedation
MIPPA Medicare Improvements for Patients and Providers Act
NAPRTCS North American Pediatric Renal Trials and Collaborative Studies
NKF National Kidney Foundation
NVASRS National VA Surgical Risk Study
PD Peritoneal dialysis
POC Point of care
PSV Peak systolic velocity
QIP Medicare Quality Incentive Program
RVU Relative value unit
SRU Society of Radiologists in Ultrasound
TDC Tunneled dialysis catheter
USRDS United States Renal Data System
VQI Vascular Quality Initiative

xv
Contributors

Suhail Ahmad Department of Medicine, Division of Nephrology, University of Washington,

Seattle, WA, USA
Nephrology Department, UW Medicine, Seattle, WA, USA
Ali Azizzadeh Department of Cardiothoracic and Vascular Surgery, McGovern Medical School
at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
Ramasamy Bakthavatsalam Transplant Surgery UWMC, Seattle, WA, USA
Lynda K. Ball ESRD Network #13, Oklahoma City, OK, USA
Ehsan Benrashid Department of Surgery, Duke University Medical Center, Durham, NC,
USA
Ruth L. Bush Department of Surgery, Texas A&M Health Science Center College of
Medicine, Bryan, TX, USA
Edward Caldwell Division of Vascular Surgery, University of Cincinnati College of
Medicine, Cincinnati, OH, USA
Marlin Wayne Causey Vascular Surgery, San Antonio Military Medical Center, San Antonio,
TX, USA
Zulfiqar F. Cheema Division of Vascular Surgery and Endovascular Therapy, The University
of Texas Medical Branch Galveston, Texas, Galveston, TX, USA
Charlie C. Cheng Division of Vascular Surgery and Endovascular Therapy, The University
of Texas Medical Branch Galveston, Texas, Galveston, TX, USA
Fionnuala C. Cormack Division of Nephrology, UW Outpatient Hemodialysis Program,
Harborview Medical Center, University of Washington Medicine Center, Seattle, WA, USA
Ellen D. Dillavou Duke University Medical Center, Durham, NC, USA
Audra A. Duncan Division of Vascular Surgery, University of Western Ontario, London, ON,
Canada
Berry Fairchild Department of Cardiothoracic and Vascular Surgery, McGovern Medical
School at The University of Texas Health Science Center at Houston (UTHealth), Houston,
TX, USA
Grant T. Fankhauser Division of Vascular Surgery and Endovascular Therapy, The
University of Texas Medical Branch Galveston, Texas, Galveston, TX, USA
Shawn M. Gage Department of Surgery, Duke University Medical Center, Durham, NC,
USA
Humacyte Incorporated, Research Triangle Park, NC, USA
Department of Surgery, Duke University School of Medicine, Durham, NC, USA

xvii
xviii Contributors

Shinobu Gamou Department of Molecular Biology, Kyorin University School of Health

Sciences, Mitaka, Japan
Kyorin CCRC Research Institute, Mitaka, Tokyo, Japan
Philip P. Goodney Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
Priyanka Govindan Division of Nephrology, UW Medical Center, Seattle, WA, USA
Sukgu M. Ham Division of Vascular Surgery and Endovascular Therapy, Keck School of
Medicine, University of Southern California, Los Angeles, CA, USA
Sung Wan Ham Division of Vascular Surgery and Endovascular Therapy, Keck School of
Medicine, University of Southern California, Los Angeles, CA, USA
Linda M. Harris Division of Vascular Surgery, University at Buffalo, SUNY, Buffalo General
Medical Center, Buffalo, NY, USA
Rachel Heneghan Division of Vascular Surgery, Department of Surgery, University of
Washington, Harborview Medical Center, Seattle, WA, USA
Sachiko Hirotani Kidney Center & Third Department of Surgery, Tokyo Women’s Medical
University, Tokyo, Japan
Karl A. Illig Division of Vascular Surgery, University of South Florida Morsani College of
Medicine, Tampa, FL, USA
C. Ingraham Division of Vascular Surgery, Department of General Surgery, The University
of Washington, Seattle, WA, USA
Christopher R. Ingraham University of Washington, Seattle, WA, USA
G. Johnson Division of Vascular Surgery, Department of General Surgery, The University
of Washington, Seattle, WA, USA
Shinya Kaname First Department of Internal Medicine, Kyorin University School of
Medicine, Tokyo, Japan
Steve Katz Division of Vascular Surgery and Endovascular Therapy, Keck School of
Medicine, University of Southern California, Los Angeles, CA, USA
Department of Surgery, Huntington Memorial Hospital, Pasadena, CA, USA
Dean Klinger Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
Ted Kohler University of Washington, Seattle, WA, USA
Peripheral Vascular Surgery, Seattle VA Puget Sound Healthcare System, Seattle, WA, USA
Jared Kray Cedar Rapids, IA, USA
Jeffrey H. Lawson Department of Surgery, Duke University Medical Center, Durham, NC,
USA
Humacyte Incorporated, Research Triangle Park, NC, USA
Department of Surgery, Duke University School of Medicine, Durham, NC, USA
Andrew E. Leake University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Cheong J. Lee Division of Vascular Surgery, Department of Surgery, Medical College of
Wisconsin, Milwaukee, WI, USA
Contributors xix

Kuo-Hua Lee Division of Nephrology, Department of Medicine, Taipei Veterans General

Hospital, Taipei, Taiwan, Republic of China
School of Medicine, National Yang Ming University, Taipei, Taiwan, Republic of China
Beatriz V. Leong General Surgery, University of Southern California, Los Angeles,
CA, USA
Chih-Ching Lin Division of Nephrology, Department of Medicine, Taipei Veterans General
Hospital, Taipei, Taiwan, Republic of China
School of Medicine, National Yang Ming University, Taipei, Taiwan, Republic of China
Thomas R. McCormick Department Bioethics and Humanities, School of Medicine,
University of Washington, Seattle, WA, USA
Rajnish Mehrotra Kidney Research Institute and Harborview Medical Center, University of
Washington, Seattle, WA, USA
George H. Meier Division of Vascular Surgery, University of Cincinnati College of Medicine,
Cincinnati, OH, USA
Brent W. Miller Division of Nephrology, Washington University, Saint Louis, MO, USA
Deepak Nair Vascular Surgery, Sarasota Memorial Hospital, Sarasota Vascular Specialists,
Sarasota, FL, USA
Koichiro Nandate Harborview Medical CtrAnsthsgy, Seattle, WA, USA
Mark R. Nehler Section of Vascular Surgery, UC Denver Colorado, Aurora, CO, USA
Bao-Ngoc Nguyen The George Washington Medical Faculty Associates, Washington, DC,
USA
W. Kirt Nichols Department of Surgery, University of Missouri – Columbia, Columbia, MO,
USA
S. Padia Division of Vascular Surgery, Department of General Surgery, The University of
Washington, Seattle, WA, USA
Seth T. Purcell Department of Surgery, Texas A&M Health Science Center College of
Medicine, Bryan, TX, USA
Baylor Scott & White Healthcare, Temple, TX, USA
David Ranney Department of Surgery, Duke University School of Medicine, Durham, NC,
USA
Shruti Rao Department of Surgery, Texas A&M Health Science Center College of Medicine,
Bryan, TX, USA
Animesh Rathore Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester,
MN, USA
Matthew B. Rivara Kidney Research Institute and Harborview Medical Center, University of
Washington, Seattle, WA, USA
Mariel Rivero Division of Vascular Surgery, University at Buffalo, SUNY, Buffalo General
Medical Center, Buffalo, NY, USA
Sean P. Roddy The Vascular Group, PLLC, Albany Medical College/Albany Medical Center
Hospital, Albany, NY, USA
xx Contributors

April Rodriguez Division of Vascular Surgery, Department of General Surgery, University of

Washington, Seattle, WA, USA
Eduardo Rodriguez Division of Vascular Surgery, University of South Florida Morsani
College of Medicine, Tampa, FL, USA
Peter J. Rossi Division of Vascular Surgery, Department of Surgery, Medical College of
Wisconsin, Milwaukee, WI, USA
Vincent L. Rowe Division of Vascular and Endovascular Surgery, Department of Surgery,
Keck School of Medicine at USC, Los Angeles, CA, USA
Sherene Shalhub Division of Vascular Surgery, Department of Surgery, The University of
Washington, Seattle, WA, USA
Susanna H. Shin Department of Surgery, University of Washington, Seattle, WA, USA
Lena Sibulesky Transplant Surgery, UW Medical Center, Seattle, WA, USA
Anton Sidawy The George Washington Medical Faculty Associates, Washington, DC, USA
Michael B. Silva Jr. Division of Vascular Surgery and Endovascular Therapy, The University
of Texas Medical Branch Galveston, Texas, Galveston, TX, USA
Niten Singh Division of Vascular Surgery, University of Washington, Seattle, WA, USA
Gale L. Tang Division of Vascular Surgery, Department of Surgery, VA Puget Sound Health
Care System/University of Washington, Seattle, WA, USA
Nam T. Tran Department of Surgery, University of Washington School of Medicine, Seattle,
WA, USA
Sandeep Vaidya Interventional Radiology, University of Washington, Seattle, WA, USA
Karim Valji University of Washington, Seattle, WA, USA
Felix Vladimir Vascular Surgery, UW Medicine, Seattle, WA, USA
Sarah M. Wartman University of Southern California, Los Angeles, CA, USA
Jennifer L. Worsham Division of Vascular Surgery and Endovascular Therapy, The
University of Texas Medical Branch Galveston, Texas, Galveston, TX, USA
Shang-Feng Yang Division of Nephrology, Department of Medicine, Cheng Hsin General
Hospital, Taipei, Taiwan, Republic of China
School of Medicine, National Yang Ming University, Taipei, Taiwan, Republic of China
Linda M. Youngwirth Department of Surgery, Duke University Medical Center, Durham,
NC, USA
Devin S. Zarkowsky Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
R. Eugene Zierler Department of Surgery, University of Washington School of Medicine,
Seattle, WA, USA
The D.E. Strandness Jr. Vascular Laboratory, University of Washington Medical Center and
Harborview Medical Center, Seattle, WA, USA
 Part I
Historical Perspectives and Current State of End
Stage Renal Disease and Hemodialysis
 Historical Perspectives on Hemodialysis
Access
Sherene Shalhub
Introduction
Nearly two centuries ago in 1836, Dr. Richard Bright
describes a composite clinical course of end-stage renal dis-
ease [1]:
The patient awakes in the morning with his face swollen, or his
ankles puffy, or his hands edematous … already his urine con-
tains a notable quantity of albumin, his pulse is full and hard, his
skin dry, he often has headaches, and sometimes a sense of
weight or pain across the loins. Under treatment more or less
active, or sometimes without treatment, the more obvious and
distressing of the symptoms disappear… absolutely forgotten.
Nevertheless, from time to time, the countenance becomes
bloated; the skin is dry; headaches occur with unusual fre-
quency; or the calls to micturition disturb the nitrous by the
repose. After a time the healthy color of the countenance fades;
a sense of weakness or pain in the lines increases; headaches
often accompanied by vomiting, add greatly to the general want
of comfort; and a sense of lassitude, or weariness and of depres-
sion, gradually steal over the body and mental frame. Again the
patient is resorted to tolerable health; again he enters is active-
duty; or he is perhaps less fortunate; the swelling increases, the
urine become scanty, the powers of life seem to yield, the lungs
become edematous, and in a state of asphyxia or coma, he sinks
into the grave; or a sudden effusion of serum into the glottis
closes the passages of air, and brings on a more sudden dissolu-
tion. Should he however have resumed avocations of life, he is
usually subject to constant recurrence of his symptoms; or again,
almost dismissing the recollection of his ailment, he is suddenly
seized with an acute attack of pericarditis, or with a still more
acute attack of peritonitis, which without any renewed warning,
deprives him in eight and 40 h, of his life. Should he escape this
danger likewise, other perils await him; his headaches have been
observed to become more frequent; the stomach more deranged;
his vision indistinct; his hearing depraved; he is suddenly seized
with a convulsive fit, and becomes blind. He struggles through
the attack; but again and again it returns; and before a day or a
week has elapsed, worn out by convulsions or overwhelmed by
coma, the painful history of his disease is closed.
S. Shalhub, MD, MPH
Division of Vascular Surgery, Department of Surgery,
The University of Washington,
1959 N.E. Pacific Street, Seattle, WA 98195, USA
e-mail: shalhub@uw.edu
© Springer International Publishing Switzerland 2017
S. Shalhub et al. (eds.), Hemodialysis Access, DOI 10.1007/978-3-319-40061-7_1
1
This background is given here because the clinical course
described is rarely seen in these modern days where dialy-
sis is taken for granted. We rarely glimpse into the vivid
reality of the deadly clinical illness that dialysis suppresses,
and because so we fail to recognize dialysis for the miracle
that it is.
The history of hemodialysis access is simply fascinating.
It is a story of pioneers in medicine who took a condition that
was a once fatal and made it a chronic condition, the story of
countless patients who were willing to undergo unproven
therapy, and the story of early organ replacement in medi-
cine. While the hemodialysis technology was being devel-
oped, the major obstacle to sustainable hemodialysis was the
limited accessibility and durability of blood vessels. This
chapter offers a historical perspective of the development of
dialysis access into the 1980s.
The First Hemodialysis in Humans
The first hemodialysis treatment in humans was performed
for 15 min on a boy dying from kidney failure by Georg Haas
(Giessen, Germany), in October 1924. He used a glass can-
nula for arterial and venous access with an inflow from the
radial artery and outflow to the cubital vein. This was the first
time that a dialysis apparatus and procedure were demon-
strated as safe and feasible. He repeated this procedure
increasing the treatment intervals for up to 60 min [2].
The treatment intervals were short due to problems with
anticoagulation. Initially, he used hirudin. In 1928 heparin
became available as an anticoagulant, and he was able to dia-
lyze 400 ml of blood by anticoagulating it and circulating it
through the dialyzer for 30 min before returning it to the
patient repeating the procedure nine times. The clinical effect
of the treatment lasted for 6 days during which the patient
clinically improved with resolution of nausea, return of appe-
tite, and a reduction in headaches. This technique did not gain
widespread recognition due to its limited efficacy [2, 3].
3
4 S. Shalhub

Modern Hemodialysis Therapy
Modern hemodialysis therapy started on March 17, 1943,
when Willem Kolff, a young Dutch physician in the small hos-
pital of Kampen (the Netherlands), treated a 29-year-old
woman suffering from malignant hypertension and “con-
tracted kidneys.” He used a “rotating drum kidney” that he
constructed with the support of Mr. Berk, the director of the
local enamel factory (Fig. 1.1). Arterial and venous access was
obtained by venipuncture needles in the femoral artery and
vein. Although that patient did not survive, he persevered in
his technique. On September 11, 1945, the first of his 17
patients survived, a 67-year-old woman with cholecystitis and
sulfonamide nephrotoxicity. Kolff left the Netherlands in 1950
and continued to work in on artificial kidneys in the United
States. In the 1950s, the technical devices were available for
regular hemodialysis treatments such as Kolff’s “twin-coil
kidney” [4]. In addition to venipuncture, he performed surgi-
cal cutdown of the radial artery, but this was complicated due
to severe bleeding during heparinization. In the years that fol-
lowed, substantial technical developments in dialysis machines
followed, but access remained a challenge.

Fig. 1.1 The first hemodialysis

machine used in the United
States: the rotating drum artificial
kidney. Top panel: the original
Kolff rotating drum dialyzer
(Image courtesy of Northwest
Kidney Centers, Seattle, WA).
Bottom panel: Kolff-Brigham
rotating drum artificial kidney on
display at Northwest Kidney
Centers’ Dialysis Museum
(Seattle, WA)
1 Historical Perspectives on Hemodialysis Access
The First Arteriovenous Shunt
The prospect of living with end-stage renal disease (ESRD)
became a reality on March 9, 1960, when a Teflon arteriove-
nous shunt made dialysis possible for a Boeing machinist,
Clyde Shields, at the University of Washington in Seattle.
Mr. Shields survived for 11 years on chronic hemodialysis
(Fig. 1.2) [5]. The original shunt was developed as a result of
the efforts of three people: Belding Scribner, the nephrolo-
gist, who came up with the concept; Wayne Quinton, the
hospital engineer, who developed the technology; and Dave
Dillard, the pediatric cardiac surgeon, who implanted the
shunt. The story of developing the shunt is recalled by
Scribner and colleagues as follows [6]:
On February 9, 1960, a 42-year-old patient, Neil Ward, was
transferred from Spokane to the University of Washington in
Seattle in a near terminal condition from uremia and congestive
heart failure or you to acute renal failure. He responded dramati-
cally to intense dialysis and ultrafiltration, and within a week he
was up and around and nearly normal health. Unfortunately,
anuria made the diagnosis of reversible renal failure suspect, and
a biopsy showed total renal destruction from rapidly progressive
glomerular nephritis. The dilemma we face is well expressed in
an expert from a letter we wrote to his referring physician on
February 25, 1960: “We have had a tremendous problem in
deciding in our own minds what the reasonable thing to do here.
His wife has been most cooperative and understanding the
dilemma, and she fully realizes the prognosis. The question was
raised as to whether he should be returned to Spokane, but his
wife said that she thought it would be better to keep him here.
We have tried to be objective and discussing his case among
ourselves, and have asked the question of whether we have the
right to prolong his life in the fashion we have. It was our feeling
Fig. 1.2 Belding Scribner (right) with Clyde Shields (left) (Image
courtesy of Northwest Kidney Centers, Seattle, WA)
5
that until we had the biopsy we could not be sure the prognosis,
and we were unable to get a biopsy until we could get him in
good enough shape to do so, hence from the point of view of the
ethics of the case, we have considered the dialysis procedure
part of our diagnosis procedure and only incidentally therapeu-
tic. Mr. Ward does seem to be enjoying his brief respite, and as
far as we or his wife are able to determine, he does not under-
stand his prognosis. By carefully observing his fluid balance, we
hope to be able to keep him free of heart failure and allow him to
slip into uremic coma, before he realizes what has happened. We
have very carefully considered the possibility of keeping him
alive and definitely by means of dialysis. And, whereas this
might be possible in a few selected cases, we have never been in
a position to attempt it, and we do not think that we would be
ready at this time, nor do we think Mr. Ward would be a candi-
date for such a drastic undertaking”. With great sadness we
finally were able to convince Mrs. Ward to take her husband
back to Spokane, where he died on March 6, 1960.
This experience caused Dr. Scribner to awaken in the
middle of a mid-February night with the idea of the arterio-
venous shunt that he subsequently developed with Wayne
Quinton and Dave Dillard. The shunt (Fig. 1.3) consisted of
Teflon tubing inserted into the radial artery and forearm vein
that can be connected to the hemodialysis machine [7]. When
not in use, the shunt was connected by a bypass loop on a
metal arm plate secured to the patient’s forearm, thus elimi-
nating the need for anticoagulation between treatments [7].
The use of Teflon tubing was important because the experi-
ence with Teflon tubing in cardiac surgery demonstrated that
the material was nonreactive and the blood did not clot off
easily in this type of tubing [2]. In 1960 there was no FDA or
device regulation; thus the shunt was implanted and used.
Scribner and Quinton presented the shunt during the annual
meeting of the American Society for Artificial Internal
Organs in Chicago [7, 8]. Several attendees took away the
materials to place in patients but had problems with the shunt.
This was attributed to lack of surgical expertise [2]. Dillard
would spend between 1 and 3 hours carefully inserting the
cannulas, and success of the shunt was attributed to his metic-
ulous surgical technique [2].
The original Teflon shunt lasted for a few weeks or
months, and the original patients including some with acute
renal failure required several shunts in the upper and lower
extremities. To increase cannula flexibility and longevity,
Quinton added a silicone rubber segment, creating the so-
called Silastic-Teflon bypass cannula where the tapered
Teflon tips were inserted into the artery and vein and a
Silastic tube made the exit through the skin (Fig. 1.4) [6].
Despite these advances, the shunts were useful only for a few
months before failing. Complications included cellulitis,
skin necrosis, sepsis, pulmonary emboli, shunt dislodgement
or cannula extrusion, vessel stenosis, hemorrhage, and
thrombosis. The mean half-life of the shunt was reported to
be 6 months [9]. Despite these complications, the shunt was
the decisive breakthrough that made maintenance hemodial-
ysis possible [3].
6 S. Shalhub
Fig. 1.3 The Quinton-Scribner arteriovenous shunt in 1960. Top
panel: Teflon tubing cannulas inserted into the radial artery and a fore-
arm vein with the bypass loop and the metal arm. Bottom panel: the
bypass loop is removed when placing the patient on hemodialysis, and
the free blood flow was controlled using a blood pressure cuff while
connecting to the dialysis machine (Courtesy of Northwest Kidney
Centers, Seattle, WA)
During these early times of hemodialysis access, candi-
dates for maintenance hemodialysis were carefully selected,
and given the limited resources, many were turned down cre-
ating national headlines [10]. The history of hemodialysis is
closely intertwined with the birth of bioethics, and this
period of evolution in medical practice is detailed by the
firsthand account of Dr. Thomas R. McCormick, Professor
of Bioethics and Humanities at the University of Washington
School of Medicine, in Chap. 8.
In 1973, T.J. Buselmeier and colleagues (Minneapolis,
USA) developed a modification of the Scribner AV shunt.
The Buselmeier shunt is a compact U-shaped Silastic pros-
thetic AV shunt with either one or two Teflon plugged outlets
which communicated to the outside of the body. The U-shaped
portion could be totally or partially implanted subcutaneously
(Fig. 1.5) [11]. This shunt was designed to address some limi-
tations of the Scribner shunt, namely, the long tubing that was
prone to dislodgment and had high resistance to blood flow,
and to limit the vascular intimal trauma that is the result of
transmitted vessel tip movement. The Buselmeier shunt
gained some acceptance during the following years, espe-
cially for pediatric hemodialysis patients [3].
The Repeated Venipuncture Technique
in Surgically Created Subcutaneous
Arteriovenous Fistula
Vascular access remained the Achilles heel of chronic hemo-
dialysis, James E. Cimino (New York, USA) observed. The
external Teflon-Silastic AV shunt (also called the Quinton-
Scribner shunt) was associated with infection and thrombo-
sis, and the alternative of repeated direct puncture of arteries
and veins damaged these conduits every time the patient was
connected to the dialysis machine. A patient could receive
only a few treatments before all available access sites were
utilized [12].
In 1961, Cimino, a nephrologist, and Michael J. Brescia
(New York, USA) described a “simple venipuncture for hemo-
dialysis” based on the experience of Cimino when he worked
part time as a student at the Bellevue Transfusion Center in
New York [13]. After infiltration of the overlying skin with
1 % procaine, the most accessible forearm vein was punctured
with a needle. Needles varied in size from 16 to 12 gauge.
Patency of the vein and adequate blood supply were assured
by the application of tourniquet pressure with a sphygmoma-
nometer. A blood flow in the range of 150 and 410 ml/min was
obtained using this technique if the patient was fluid over-
loaded, but this was not sustainable in hypovolemic patients.
Cimino also noted that arteriovenous fistulas (AVFs)
caused by trauma in Korean War veterans did not have signifi-
cant effects on their health. Additionally, experience with sur-
gically created fistulas was not new. During the 1930s,
surgically created fistulas were placed at the Mayo Clinic in
children with polio whose legs were paralyzed and not grow-
ing in order to promote collateral circulation. Cimino began to
wonder if they could take advantage of the rapid blood flow
and accompanying venous distention that occurred in the pres-
ence of a surgically created AVF despite the risk of developing
1 Historical Perspectives on Hemodialysis Access
Fig. 1.4 The original Teflon Quinton-Scribner arteriovenous shunt as
first designed in 1960 (top panel) and the developmental progression of
the shunts from 1960–1967 (bottom panel, left to right) and the addition
of the silicone rubber segment, creating the Silastic-Teflon bypass can-
heart failure as a long-term consequence. Dr. Cimino remarks
that “We were bold in using a procedure that had always been
considered physiologically abnormal, but without adequate
vascular access our patients were doomed” [12].
On February 19, 1965, Drs. Brescia, Cimino, and Appel
(surgeon) created the first autogenous arteriovenous fistula
[14]. Dr. Appel performed a side-to-side anastomosis
between the radial artery and the cephalic vein at the wrist
using a 3–5 mm arteriotomy and venotomy in the corre-
sponding lateral surfaces of the artery and the vein using
arterial silk in continuous fashion for the anastomosis [14].
The fistula could then be accessed for dialysis by venipunc-
ture. The first AV fistula dialysis attempt failed. Later, they
realized it had failed for the same reason the original vein-to-
vein technique had failed. “The patient had been prepared so
7
nula with tapered Teflon tips that were inserted into the artery and vein
and the Silastic tube to exit through the skin (shunts photographed at the
Northwest Kidney Centers’ Dialysis Museum, Seattle, WA)
diligently before the procedure that we removed too much
fluid,” Cimino says. “His blood pressure was inadequate for
keeping blood flowing through the newly created fistula.”
After a period of trial and error, Cimino and his team were
able to maintain adequate blood flow by using carefully
placed tourniquets. They also found that despite their fears of
inducing congestive heart failure from the fistula creation,
patients’ cardiac function remained stable or improved
following the creation of a fistula. By 1966, an additional 14
operations followed. He presented the result of his work at
the Congress of the American Society for Artificial Internal
Organs. Twelve of the 14 AVFs functioned without compli-
cations, two never worked (in the first patient, the anastomo-
sis “was made too small”) [14]. To his surprise, the audience
reacted with complete indifference [12] though over time
8 S. Shalhub
Fig. 1.5 A schematic of the
U-shaped Silastic prosthetic
Buselmeier arteriovenous shunt
used in the 1970s with two Teflon
plugged outlets that
Teflon plug
communicated to the outside of
the body. The U-shaped portion
could be totally or partially Venous
return port
implanted subcutaneously
Teflon vessel tip
Great
saphenous
vein
Anastomosis
this changed; Dr. Scribner from Seattle was the first nephrol-
ogist to refer one of his patients to New York for the creation
of an AVF [15].
The evolution of the hemodialysis access continued when
M. Sperling (Würzburg, Germany) reported the successful
creation of an end-to-end anastomosis between the radial
artery and the cephalic antebrachial vein in the forearm of 15
patients using a stapler in 1967 [16]. The creation of the end-
to-end anastomosis was technically challenging and the
diameters of the artery and vein were different. Thus this
type of AVF was abandoned.
In 1968, Lars Rohl (Heidelberg, Germany) published the
results of 30 cases where he used an end-to-side cephalic vein
to radial artery anastomosis [17].After completion of the
anastomosis, the radial artery was ligated distal to the anasto-
mosis, resulting in a functional end-to-end anastomosis. With
this technique, an antebrachial cephalic vein located at a more
lateral position in the forearm, thus not suitable for a side-to-
side anastomosis, could be used successfully. Later on, the
ligation of the radial artery distal to the anastomosis was used
in patients with impending signs of peripheral ischemia [17].
Alternatives to the wrist AVF were being explored during
the same time period. In 1969 W.D. Brittinger (Mannheim,
Germany) published his case series of 17 patients who
underwent successful “Shuntless hemodialysis by means of
puncture of the subcutaneously fixed superficial femoral
artery for chronic hemodialysis” [18]. Following a femoral
Cephalic vein
Arterial
silastic tube
Radial artery
Anastomosis
Silastic tube
Superficial
femoral artery
arteriogram to exclude arterial anomalies or disease, the
superficial femoral artery was exposed by mobilizing the
sartorius muscle which was then transected, passed under-
neath the exposed artery, and joined again. The fascia lata
was closed, ensuring that proximal and distal openings of
the fascia were sufficiently large to prevent compression of
the artery [3].
Another technique was that of mobilizing and fixing the
radial artery underneath the skin throughout its length along
the forearm by G. Capodicasa (Naples, Italy). However,
there were no further publications to confirm the value of this
procedure [3].
Dialysis Catheters
Dialysis catheters developed along the same timeline as the
AV shunt and AVF were being developed. Initially due to
necessity, as not all centers had the expertise to offer AV
shunt placement, and later a debate ensued as to whether an
AVF or an indwelling shunt is superior in providing vascular
access [19]. AVF challenges included vein tortuosity making
needle insertion difficult, patient anxiety related to venipunc-
ture, and inability by trained personnel to repeatedly achieve
successful venipuncture despite adequate AVF [19].
In the 1960s, while the external Teflon-Silastic AV shunt was
gaining popularity, not all surgeons were willing to perform
1 Historical Perspectives on Hemodialysis Access 9

the operation to place the shunt [20]. This led Stanley Shaldon Site of venous Exit site
insertion
(London, UK), a nephrologist, to introduce handmade catheters
into the femoral artery and vein by the percutaneous Seldinger
technique for immediate vascular access [20, 21]. Over time,
vessels in different sites were used, including the subclavian
vein. Shaldon concluded: “Eventually, veno-venous catheter-
ization was preferred because the bleeding from the femoral
vein was less than from the femoral artery when the catheter
was removed” [20].
Vein
After the first use of the subclavian route for hemodialysis Fistula

access by Shaldon in 1961, the technique was adapted by Artery

Josef Erben (former Czechoslovakia), using the infraclavicu-

lar route [22]. Dr. Erben reported that single-needle hemodi-
alysis using subclavian or femoral vein cannulation gave the
same results as the arteriovenous radiocephalic fistula; thus
intermittent or combined use of both types of large vein can-
nulation is advantageous in long-term regular dialysis patients
that are waiting for a new fistula [22]. The main risk of sub-
clavian vein cannulation was bleeding due to arterial access
and pneumothorax. The associated mortality rate was 0.12 %
due to subclavian vein cannulation and 0.04 % due to femoral
vein cannulation [22]. During the following 2 decades, the
subclavian approach became the preferred route for tempo-
rary vascular access by central venous catheterization [3].
In 1972, James J. Cole, Robert O. Hickman, Belding
H. Scribner, and colleagues (Seattle, WA, USA) presented a
new concept “the fistula catheter.” The design was extrapo-
lated from the indwelling intravenous feeding catheter for
hyperalimentation. They reasoned that placement of cathe-
ters of appropriate design in the high-flow environment in a
vein proximal on an AVF might result in the creation of a
thrombus-free, nonreactive semipermanent hemodialysis
access. The catheters were designed as a single Silastic tube
with an attached Dacron velour cuff for external fitting or a
double-lumen implant consisting of a paired Silastic tubes
bonded together and introduced into the fistula at a single
entry point (Fig. 1.6).
Hybrid External Arteriovenous Shunts
Limitations of the Teflon-Silastic AV shunt and dialysis cath-
eters were becoming obvious over time. As multiple revisions
are performed on the patients, cannulation sites become fewer
and fewer. These repeat operations were noted to be difficult
for the patient and surgeon as they became longer and longer
in an attempt to explore and find satisfactory arteries and
veins for cannula sites [23]. In hopes of providing the patient
with a permanent AV shunting system and based on animal
experiments, Dr. George I. Thomas (Seattle, USA) felt that
certain principles of restorative vascular and prosthetic sur-
gery could be applied to eliminate some of these problems.
These principles included removing all foreign bodies from
Fistula Vein
Artery
Fig. 1.6 A schematic of the fistula catheter used in the 1970s. Top
panel: using two single catheters inserted at separate entry points.
Bottom panel: using a double catheter
the vessel lumen to eliminate vessel stenosis, applying graft
material at all vessel junctions to obtain good healing, and
avoiding thromboembolism by maintaining continued blood
flow in the host vessel. Dr. Thomas presented his cases series
in ten patients using the “Dacron appliqué shunt” technique
in 1970. In this technique he sutured oval Dacron patches to
the common femoral artery and the saphenous/common fem-
oral vein [23]. The Dacron patches were connected with
Silastic tubes and brought to the surface of the anterior thigh
approximately 10 cm distal to the femoral incision (Fig. 1.7).
In reviewing a more recent history, a retrospective study pub-
lished in 2001 of 27 femoro-femoral Thomas shunts implanted
in ten patients (ages 27–75 years) who had 80 failed vascular
accesses (average of 8.6 accesses per patient). The average
shunt duration was 43.7 months (range 3–151 months). One
and two year survival rates were 85 % and 57 %, respectively.
Five patients spent more than 10 years on maintenance hemo-
dialysis using the Thomas shunt. Complications included
infection (one episode every 37.5 patient-months), thrombo-
sis, and stenosis. Percutaneous angioplasty was successful in
the majority of stenosis episodes. The authors concluded that
his shunt offers high dialysis efficacy without recirculation
and access duration comparable to AVF [24].
10
Dacron cuffs
Femoral
artery
Femoral
vein
Subcutaneous
tunnel
Venous
Arterial branch
branch
Teflon connector
Fig. 1.7 A schematic of a right thigh femoro-femoral Thomas arterio-
venous shunt that was used in the 1970s: oval Dacron patches were
sutured to the common femoral artery and the common femoral vein
and then connected to Silastic tubes tunneled subcutaneously to the sur-
face of the anterior thigh approximately 10 cm distal to the femoral
incision
Alternative Conduits in Dialysis Access
Limitations of the autogenous radiocephalic arteriovenous
fistula included lack of maturation that led to a search for
alternative conduits for the venipuncture hemodialysis tech-
nique. In 1972, the bovine carotid artery graft and the Dacron
velour vascular graft were introduced. The modified bovine
carotid artery biologic graft for vascular access (Artegraft,
Johnson & Johnson), was the first xenograft used and was
introduced by Joel L. Chinitz (Philadelphia, USA) in a case
series of eight hemodialysis patients [25]. The graft received
some acceptance during the 1970s. The technique described
included upper (four cases) and lower extremity (four cases)
arteriovenous grafts. The venous anastomosis is sutured with
6.0 Dacron sutures, while the arterial anastomosis is sutured
with 5.0 Dacron suture and the graft proximal section tight-
ened with a Dacron cuff to reduce the diameter in a tapered
manner to 5 mm Dacron velour vascular graft. In the same
year, Irving Dunn (Brooklyn, USA) chose Dacron velour
vascular graft for the creation of AV bridge grafts, initially in
animal experiments and then in a uremic female patient [26].
Subsequently, this material did not yield satisfactory results
for vascular access.
The use of mandril grafts was described by R.K. Beemer
(Portland, USA) in 1973 [27]. Mandril grafts are reinforced
autogenous graft grown in situ. This technique was origi-
nally developed by Charles H. Sparks (Portland, USA) based
S. Shalhub
on a series of animal experiments starting in 1965 to create
an alternative to the great saphenous vein conduits for femo-
ral popliteal bypass [28]. The technique consisted of prepar-
ing a smooth silicone rubber rod of desired diameter and
length with a covering or coverings of specially prepared,
large-mesh, knitted Dacron tubes and implanting the result-
ing assembly in the location of the contemplated arterial
grafting procedure [29]. It was left in place for 6 weeks so
that the Dacron mesh became organized after invasion of the
surrounding tissue. The mandril was then removed and the
endings of the matured subcutaneous tunnel were anasto-
mosed to the native vessels. Beemer described patients with
inadequate superficial veins in the forearm for AVF creation.
He implanted the mandril graft in the forearm in a straight
configuration between the radial artery at the wrist and the
basilic vein in the arm (four cases) or in a forearm loop con-
figuration between the brachial artery and basilic vein. The
silicone rods were removed after 6 weeks and the anastomo-
ses made [27]. Because of the unfavorable results and the
availability of more successful prosthetic materials, this
technique was abandoned a few years later.
In 1975 and 1976, two groups detailed experiences with
the use of human umbilical cord vein. The enthusiasm for this
conduit was due to the perceived advantages of an antithrom-
bogenic intimal surface and the absence of valves and
branches. B.P. Mindich (New York, USA) used chemically
processed umbilical cord veins without external support [30],
whereas H. Dardik (New York, USA) surrounded the graft
with a polyester fiber mesh [31]. This conduit did not achieve
a real breakthrough because of insufficient resistance against
the trauma of repeated cannulation and of problematic surgi-
cal revision in the case of aneurysms and infection.
In 1976, L.D. Baker Jr. (Phoenix, USA) presented the first
results with expanded PTFE grafts in 72 hemodialysis
patients [32]. The majority of these grafts were 8 mm in
diameter. Numerous publications during the subsequent
years demonstrated the value and the limitations of this pros-
thetic material, which has remained the first choice of grafts
for vascular hemodialysis access even today.
The No-Needle Dialysis
In 1981, A.L. Golding and colleagues (Los Angeles, USA)
developed a “carbon transcutaneous hemodialysis access
device” (CTAD), commonly known as “button,” as a means
for a “no-needle dialysis” approach [9]. This was in response
to reports of many patients not tolerating repeated needle
punctures well and requiring “desensitization therapy by a
psychiatrist” [9]. The repeated needle puncture was a deter-
rent to home hemodialysis, and when unsuccessful, it leads
patients to switch to peritoneal dialysis or transplantation
[9]. The device consisted of two components: a vitreous
1 Historical Perspectives on Hemodialysis Access
Fig. 1.8 The carbon transcutaneous hemodialysis access device com-
monly known as “button” for a “no-needle dialysis” approach. (a) The
design of the device. (b) The device with the connector allowing hemo-
dialysis (Reproduced with permission Nissenson et al. [9])
carbon access port sealed with a conical polyethylene plug
and a PTFE graft attached to the port (Fig. 1.8). A disposable
connector provides for the movement of blood from the
device into and out of the dialyzer. The authors reported a
case series of 21 of the devices implanted in 18 patients.
Overall the 9-month patency rate is 64.3 %, comparing favor-
ably with conventional PTFE grafts. These devices were
expensive and never gained widespread acceptance [3].
In 1983, J.L. Wellington (Ottawa, Canada) reported a case
series of implanted “buttons” developed by F.L. Shapiro [33]
(Minneapolis, USA), a device similar to that developed by
Golding. Wellington implanted these buttons along an arteri-
alized, superficialized basilic vein, but the results were dis-
appointing [3].
Final Remarks and Conclusions
Vascular access for hemodialysis is closely associated with
the history of dialysis. This was a chapter written from the
perspective of a vascular surgeon and thus did not delve
greatly into the history of dialysis machine and technology
development. This, too, has its own rich history. Throughout
the book, the history of dialysis access continues to unfold
11
as each of the authors adds elements of historical perspec-
tive as they deem relevant to their chapter topic thus adding
to our knowledge about how our practice continued to
evolve.
Acknowledgments I am greatly indebted to Elizabeth Faye, Archivist,
and Linda Sellers, Director of Public Relations at Northwest Kidney
Centers for their assistance with the tour of the Dialysis Museum in
Seattle and providing some of the historic photos in this chapter.
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 The Natural History of Hemodialysis
Access
Fionnuala C. Cormack
Background
One of the most critical aspects of planning for long-term
hemodialysis (HD) is obtaining vascular access. The prospect
of living with end-stage renal disease (ESRD) became a reality
in 1960 when Belding Scribner, in collaboration with Wayne
Quinton and David Dillard, developed a Teflon arteriovenous
shunt which enabled Boeing machinist Clyde Shields to sur-
vive for 11 years on chronic hemodialysis. The shunt consisted
of Teflon tubing inserted into the radial artery and forearm vein,
connected by a bypass loop on a metal arm plate when the
patient was not dialyzing [1]. To increase cannula flexibility
and longevity, Quinton later added a silicone rubber segment,
creating the so-called Silastic-Teflon bypass cannula where a
tapered Teflon tip was inserted into the blood vessel and a
Silastic tube made the exit through the skin [2]. Shortly there-
after, in 1965, Drs. Brescia, Cimino, and Appel created the first
autogenous arteriovenous fistula by creating a side-to-side
anastomosis between a radial artery and cephalic vein. These
first fistulas were cannulated within a day of creation [3].
It is widely accepted that native arteriovenous fistulas
(AVF) are the preferred hemodialysis vascular access [4]. AVF
have lower complication and infection rates and longer sur-
vival and superior patency, provide consistently adequate dial-
ysis, cost less, and are associated with decreased morbidity
and mortality when compared to arteriovenous grafts (AVGs)
and tunneled central venous catheters (CVCs) [5–14].
As the ESRD population expanded in the 30 years after
the development of arteriovenous (AV) fistulas, so too did
options for prosthetic AV accesses. In the 1990s, the pre-
dominant form of vascular access was the polytetrafluoroeth-
ylene (PTFE) graft [15]. For the 1990 incident cohort of
hemodialysis patients, the rate of AV graft placement was
F.C. Cormack, MD
Division of Nephrology, UW Outpatient Hemodialysis Program,
Harborview Medical Center, University of Washington
Medicine Center, 325 Ninth Avenue,
Box 359606, Seattle, WA 98104, USA
e-mail: dubh@uw.edu
© Springer International Publishing Switzerland 2017
S. Shalhub et al. (eds.), Hemodialysis Access, DOI 10.1007/978-3-319-40061-7_2
2
1.7 that of AVF construction [16]. High reliance on AVGs
was associated with significantly increased cost, with grafts
having three to sevenfold greater access complications com-
pared with AV fistulas [17, 18].
In 2003, in response to rising costs, increased morbidity
and mortality associated with AVG and catheter use, and a low
prevalent AVF rate at 32 %, the Centers for Medicare and
Medicaid Services (CMS), along with the End-Stage Renal
Disease (ESRD) Networks, the Institute for Healthcare
Improvement (IHI), and dialysis stakeholders, joined forces to
establish the National Vascular Access Improvement Initiative
(NVAII), a continuous quality improvement project aimed at
increasing autogenous arteriovenous fistula use. In 2005
NVAII became known as the Fistula First Breakthrough
Initiative (FFBI) [19]. The FFBI led to a national push by
CMS and the dialysis community to increase the placement of
functioning AVFs in patients undergoing hemodialysis in the
USA. The original goal was for 60 % AV fistulas among inci-
dent and 40 % among prevalent hemodialysis patients, in line
with the National Kidney Foundation Kidney Disease
Outcomes Quality Initiative (NKF KDOQI) target [10]. In
2009, FFBI set a goal of 66 % AV fistula utilization in preva-
lent hemodialysis patients, a target similar to AVF prevalence
in Europe and Asia, as reported in the Dialysis Outcomes and
Practice Patterns Study (DOPPS), an international prospective
observational study of an international prosective observa-
tional study of hemodialysis practices and patient outcomes
[20]. The FFBI outlined strategies or “change concepts” to
facilitate a multidisciplinary approach among nephrologists,
dialysis personnel, vascular access surgeons, and patients to
increase the production and use of autogenous AV accesses.
Epidemiology
In 2011, 430, 273 patients were on dialysis, of which 395,656
patients (92 %) were undergoing hemodialysis in the USA.
103,744 patients initiated hemodialysis in that year [21].
Hemodialysis is the most common dialysis modality
13
14
worldwide. In over 76 % of reporting countries, at least 80 %
of patients are on hemodialysis [22]. Despite improvements
in survival in recent years, mortality in the dialysis population
is ten times greater than among Medicare patients of similar
age without kidney disease. Forty-six percent of ESRD
patients die within three years of starting hemodialysis [23].
Most deaths occur in the first year of dialysis initiation.
Among 2011 incident hemodialysis patients, all-cause mor-
tality was 421 deaths per 1000 patient-years in month 2,
decreasing to 193 per 1000 patient-years in month 12 [23].
The rates of infection-related deaths were 38 per 1000 patient-
years at month 3 and fell to 17 by month 12. There is consis-
tent evidence that infection-related deaths are related to
catheter use and that mortality is reduced when dialysis
patients switch to an AV fistula or AV graft within the first
year of dialysis initiation [24, 25]. In 2010, the three-month
mortality for patients initiating dialysis with a catheter was
9.7 % versus 3.1 % for patients dialyzing with an AVF [26].
Twenty-six percent of patients starting dialysis with a catheter
died within 12 months, compared to 11 and 16 % in patients
initiating with an AVF and AVG, respectively [26].
As a result of the efforts of the FFBI, the national preva-
lent rate for native arteriovenous fistulas in the USA among
in-center and home hemodialysis patients almost doubled in
the last decade, increasing from 32 to 61 % [27]. Using data
from DOPPS, Pisoni et al. reported AVF use increased from
24 % in 1997 to 68 % in 2013. Internationally, among 20
countries studied in 2012–2013, the USA fell in the middle
with respect to AVF and CVC use, but had the highest AVG
use among all DOPPS countries at 18 %. AV access differs
by race with 58 % AVF use in black patients, compared with
74 % in Hispanic and 70 % in white patients. Further, AVG
use was twofold higher among black versus nonblack HD
patients. There was no significant difference in CVC use
among the three groups. Lower AVF use was also found in
women with 50 % for black women versus 65 % for black
men and 65 % for nonblack woman versus 75 % for nonblack
men. CVC use was 1.4- to 1.5-fold higher among women
100
80
Percentage of patients
60
40
20
Fig. 2.1 Vascular access use at
the initiation of dialysis. Eighty
percent of patients initiate dialysis
with a catheter
F.C. Cormack
versus men. Allon et al. noted 30 % less AVF creation in
women versus men and blacks versus whites, suggesting that
women and black patients are likely deemed poor candidates
for AVF placement, perhaps due to smaller vessel size [28].
Despite an increase in fistula use among prevalent hemodi-
alysis patients in recent years, catheter utilization remains unac-
ceptably high in both incident and prevalent HD patients, and
there has not been significant improvement in the number of
patients initiating dialysis with a functional AV fistula. According
to the United States Renal Data System (USRDS), in 2011,
approximately 80 % of incident hemodialysis patients initiated
treatment with a catheter as their vascular access (Fig. 2.1) [21].
This number has remained relatively unchanged since 2005. Of
these, only 17 % had a maturing AVF and 1.6 % a maturing
AVG. Even among hemodialysis patients followed by a nephrol-
ogist for over 12 months prior to starting ESRD therapy, 63 %
started hemodialysis with a catheter. Reassuringly, a greater per-
centage had an arteriovenous fistula or AVG, at 31.9 and 20.8 %,
respectively. Ninety-five percent of patients with no nephrology
care started treatment with a catheter, with only 14 % having a
maturing AVF or AVG. In the USA, significantly fewer patients
initiate dialysis with a functional vascular access, compared to
other countries where AVF use among incident patients is
50–60 % in most European countries and 84 % in Japan.
Complications of Catheter Use
In 2011, USRDS reported that 51 % of hemodialysis patients
were dialyzing with a catheter at day 91 of treatment.
According to US DOPPS, 19–38 % of patients were dialyz-
ing with a CVC in 2013 [29]. FFBI has set a goal to decrease
catheter use to <10 % for patients on HD longer than 90 days.
In fact, in recent years, the FFBI has transitioned to the
Fistula First Catheter Last (FFCL) Workgroup Coalition “to
focus on the development of tools and resources to help dial-
ysis facilities and clinicians reduce catheters and increase
AV fistula rates in hemodialysis patients” [19]. Catheter use
Catheter
Catheter with maturing fistula
Catheter with maturing graft
AV fistula
AV graft
0
All No nephrologist Nephrologist > 12 mo
2 The Natural History of Hemodialysis Access
is associated with significant morbidity, mortality, and cost.
A major complication of catheter use is catheter-related bac-
teremia and the attendant risks of hematogenous spread
causing complications such as endocarditis, septic emboli,
and osteomyelitis. The cumulative risk of an episode of
catheter-related bacteremia is close to 50 % in the first
6 months of use, and each hospitalization for catheter-related
bacteremia costs around $23,000 [30, 31]. One study reports
a threefold increased mortality in patients dialyzing through
catheters compared to AVFs [7]. In one large cohort of
almost 80,000 patients, changing from a catheter to a fistula
or graft significantly improved patient survival, with a 30 %
decrease in risk of death in prevalent hemodialysis patients
[24]. With respect to impact on future vascular access,
Rayner et al. found prior catheter use was associated with a
significantly increased risk of fistula failure [32].
Many factors contribute to the increased use of catheters
in incident hemodialysis patients [33]. While many point to
delayed nephrology referral, as shown above, even among
patients followed by a nephrologist for a year, 60 % initiate
hemodialysis with a catheter in place. Some posit that
attempting fistula placement in the vast majority of patients
has the potential to increase catheter use, compromise vascu-
lature for future vascular accesses, and necessitate more
interventions for salvaging the existing access and creating a
new vascular access [26, 34–36].
While a functioning fistula is the gold standard of vascu-
lar access and is associated with the best outcomes, AVF
may not be the optimal choice for all patients [37]. For
instance, AV fistulas may not be the best choice for patients
who are older and have multiple comorbidities, shorter life
expectancy, or unsuitable vessels. In such cases, AV grafts
may be a more appropriate HD access and may translate
into less catheter use [38]. In the 2006 guidelines for vascu-
lar access, the KDOQI Work Group recognized that the “fis-
tula first at all costs” approach may not be the optimal
approach for all patients [10]. Many now agree that a uni-
versal policy of fistula first may not be appropriate for all
incident patients and, instead, providers should take a
patient-centered approach in determining the optimal vascu-
lar access. Factors affecting the reduced number of working
fistulas at dialysis start and contributing to increased cathe-
ter time, as discussed below, include (1) inadequate timing
of vascular access placement, (2) fistula nonmaturation, (3)
inadequate fistula surveillance postoperatively, and (4) inad-
equate reimbursement for vascular access procedures.
Timing of Vascular Access Placement
Establishing a functional AV fistula takes time. There are a
number of steps involved in vascular access placement: refer-
ral to surgery, surgical evaluation, scheduling the surgery,
15
time for maturation, and the possibility of a need for a salvage
procedure to achieve usability [39].
Even among those patients followed by a nephrologist,
the above process is often not initiated with sufficient time to
ensure patients initiate hemodialysis with a mature fistula.
KDOQI encourages educating patients with a glomerular fil-
tration rate (GFR) less than 30 ml/min/1.73 m2 on all modali-
ties of kidney replacement therapy, so that timely referral can
be made and a permanent dialysis access placed, when indi-
cated. Both KDOQI and the Society for Vascular Surgery
(SVS) recommend that an AVF should be placed at least
6 months in advance of the anticipated need to start hemodi-
alysis [10, 12]. This timing allows for adequate maturation,
as well as potential revisions or placement of a new vascular
access when an access fails to mature.
A complicating factor in timely vascular access creation
is the difficulty in accurately predicting the rate of progres-
sion of kidney failure, especially in cases of acute-on-chronic
kidney injury where patients need to initiate dialysis urgently
[33]. Further, many patients resist permanent access place-
ment, hoping their kidney function will stabilize with
improved blood pressure and glycemic management [33].
Regarding surgical planning, KDOQI recommends
duplex ultrasound of the upper extremity arteries and veins.
Routine preoperative vessel mapping has not consistently
translated into improved fistula maturation rates. Preoperative
mapping is associated with an increase in fistula placement
in several observational studies, but is not necessarily associ-
ated with improved maturation [40]. Patel et al. reported
increased fistula creation from 61 to 73 % but decreased mat-
uration rate from 73 to 57 % after implementing preoperative
vascular ultrasounds [41]. In another study, radiocephalic
fistulas constructed with veins less than 2.0 mm had a pri-
mary patency of 16 % at 3 months compared with 76 % with
veins greater than 2.0 mm [42]. Wong et al. reported that
when the radial artery or cephalic vein diameter was
<1.6 mm, fistulas did not mature [43]. Peterson et al. found
that older age, female gender, and forearm location were
associated with a significantly higher risk of primary fistula
failure despite adequate preoperative vessel size [44]. Most
studies support a minimum vein diameter of 2.5 mm and
artery diameter of 2 mm for successful fistula creation.
There are no randomized controlled trials comparing ana-
tomic order with respect to access construction. Both SVS
and KDOQI recommend that the first access should be placed
as far distally as possible to preserve proximal sites for future
accesses. Per KDOQI, “good surgical practice makes it obvi-
ous that when planning permanent access placement, one
should always consider the most distal site possible” [10]. In
patients with small vessels, some advocate for the placement
of a forearm AV graft to mature upper arm veins, which both
enables a future successful upper arm AVF and provides a
functioning access without the need for catheter use.
Another random document with
no related content on Scribd:
 The two men were lying in the shade of an S. E. 5 wing on the line
in front of the Engineering Department hangars.
“Where’s Covington now? By the time he gets through testing that
Martin it’ll have flown twice as far as we’re going to fly it and be all
ready to get out of whack again,” remarked Hinkley, rolling a stem of
grass around in between his lips.
“It’ll be right when we get it though. Did he say it was fully
equipped?”
Hinkley nodded.
“Even our suitcases are in, and artillery enough to equip all the
armies of the allies. That’s the ship now, isn’t it?”
Both men watched the Martin which was gliding majestically over
the hangars on the Western edge of the field. It was wide and squat-
looking, the one motor on each wing with the nose of the observers
cockpit between giving it the impression of a monster with a face.
Over seventy feet of wing-spread, two Liberty motors, weighing
nearly five tons with a full load—it seemed so massive that the idea
of flying it would have been ridiculous to a landsman who had never
seen one in the air. There was none of the lightness and trimness
usually associated with airplanes.
It squatted easily on the ground, the high landing gear thrusting
the nose ten feet in the air as it landed. It came taxying slowly toward
the waiting pilots.
“Ready to go, I see.”
Broughton sat up and Hinkley turned at the sound of Graves’
voice. He was already in coveralls. The open neck showed the stiff-
standing collar of an army uniform with officers’ insignia on it.
“Yes, sir. And you?”
“Right now. Is there anything more to be done to the ship?”
“Not unless Covington has discovered something in this flight,”
replied Broughton. “A little more gas and oil to make up for what
Covey has just used and we’ll be set.”
Conversation became impossible as the ship rumbled up to the
line. Using first one motor and then the other, depending on which
way he wanted to turn, Covington brought the bomber squarely up to
the waiting-blocks. The attentive ears of the flyers listened closely to
the sweet idling of both motors while Covington waited in the cockpit
for the gas in the carburetors to be used up before cutting his
switches.
“Listens well,” stated Hinkley.
Broughton nodded.
“While they’re filling it with gas let’s make sure we understand
everything,” said Graves. “This will probably be our last opportunity
to talk.”
“Let’s see what Covey says first,” suggested Broughton.
The test pilot, a chunky young man with nearly three thousand
hours in the air on over sixty types of ships, assured them briefly that
everything was in apple-pie condition. And when Covington said a
ship was right, few men in the Air Service made even a casual
inspection to verify it.
“We’ll have her filled in five minutes or so. Where in ⸺ are you
bound, anyway?” he inquired curiously. “You’ve had us flying around
here as busy as “Lamb” Jackson getting ready for a flight.”
This irreverent reference to an officer who flew semi-occasionally
to the accompaniment of enough rushing around on the part of
mechanics to get the whole brigade in the air caused Broughton to
grin widely.
“We’re carrying Colonel Graves here to Dayton, and want to be
prepared for a forced landing. There’s a little unrest among the
miners, over in West Virginia, you know.”
“There’ll be more if all that artillery gets into action,” returned
Covington. “Well, good luck. I’ve got to take up this ⸺ Caproni and
find out⸺”

A sickening crash made the heads of all four men jerk around it as
though pulled by one string. On the extreme western edge of the
field a mass of smoke with licking flames showing through hid a De
Haviland, upside down.
“Hit those trees with a wing and came down upside down,” came
the quiet voice of Graves. His face was white to the lips.
Covington rushed into the hangar, bound for a telephone. Before
he reached it there came two explosions in rapid succession. Then a
blackened figure, crawling over the ground away from the burning
ship.
Neither flyer had spoken. They watched fire engines and
ambulances rush across the field, and saw that horrible figure
disappear behind a wall of men. Came a third explosion.
“Bombs,” said Hinkley.
“Two cadets from the 18th Squadron,” yelled Covington from the
hangar door.
“Tough luck,” said Broughton, his tanned face somber.
Graves, still white, looked at the flyers curiously. In his eyes there
was suddenly sympathy, and understanding, but no trace of fear.
“I suppose there is no chance for either of them?” he asked.
“Not a bit.”
“Words are rather futile, aren’t they? But if you don’t mind, let’s
make sure we understand each other now so that there will be no
question of our procedure, insofar as we can lay it out ahead of
time.”
Mechanics had resumed their work after the brief flurry caused by
the accident, and several of them swarmed over the Martin,
supplying it with gas and oil in each motor. There was very little to be
said by Graves, except to emphasize previous instructions.
“I am banking on their respect for the United States Army—
something which no class of people ever loses. I hope it will be fear
and respect mingled, and that not even Hayden, suspicious as he
will be, will dare fool with army officers. You both have shoulder
holsters as well as your belts?”
Both men nodded.
“That’s all then, I guess.”
“And the ship is ready,” said Hinkley.
“I left my helmet over in the hangar. I’ll be right out,” said Graves.
He started for the hangar with long, unhurried strides.
“Larry, I’m growing to believe that this man Graves has got
something on the ball,” Broughton remarked slowly as they walked
toward the ship. “In addition, he’s got nerve.”
That was a lot for Broughton to say on short acquaintance, and
Hinkley knew it.
 “I wouldn’t trust any man in the world in a knockdown fight as far
as I could throw this Martin, Jim, without seeing him there first,” the
tail pilot said. “But I feel a lot easier in my mind!”

IV.
Graves climbed in the observer’s cockpit, which is the extreme
nose of the ship. Directly behind him, seated side by side and
separated from him only by the instrument board, were Broughton
and Hinkley. Broughton was behind the wheel. On the scarf-mount
around the observer’s cockpit a double Lewis machine-gun was
mounted. Several feet back of the front cockpits, where a mechanic
ordinarily rode, another twin Lewis was mounted on a similar scarf-
mount.
Broughton turned on the gas levers, retarded the two spark
throttles, and with his hand on the switches of the right-hand motor
waited for the mechanics to finish swinging the propeller.
“Clear!” shouted one of them.
Jim clicked on the switches and pressed the starter. The propeller
turned lazily, the motor droning slightly as an automobile motor does
when the starter is working. In a few seconds she caught. Similar
procedure with the left-hand motor, and shortly both Libertys were
idling gently.
Broughton’s eyes roved over the complicated instrument board
before him. Two tachometers, two air-pressure gages, two for
temperature, air-speed meter, two sets of switches, starting buttons,
double spark, double throttle, and on the sides of the cockpit shutter
levers, gas levers, landing lights and parachute flare releases—it
was a staggering maze to the uninitiated, but the two airmen read
them automatically. From time to time they turned to watch more
instruments set on the sides of the motors; oil-pressure gages, and
additional air-pressure and temperature instruments, to say nothing
of gages to tell how much gas and oil they had.
 Finally the pilot’s hand dropped to the two throttles set side by
side on his right hand. Little by little he inched them ahead until both
motors were turning nine hundred. He left them there a moment,
watching the temperatures until one read sixty and the other sixty-
five. He cut the throttle of the left-hand motor back to idling speed,
and then slowly opened the right one until the tachometer showed
twelve hundred and fifty. He let it run briefly on each switch alone,
listening to the unbroken drum of the cylinders. He went through the
same routine with the left motor before he allowed both motors to
idle while mechanics pulled the heavy blocks.
The ship was headed toward the hangars. When the block was
pulled the right-hand motor roared wide open. Without moving
forward three feet the great ship turned in its tracks, to the left. After
it was turned it bumped slowly out for the take-off.
You can almost tell a Martin pilot by his taxying. The least
discrepancy in the speed of either motor will make the ship veer.
There is a constant and delicate use of the throttles to hold it to a
straight course, without getting excessive speed. The two big
rudders, both attached to one rudder bar, have little effect on the
ground.
With a tremendous roar the Martin sprang into life. Jim set himself
against the wheel with all his strength to get the tail up. As soon as
that effort was over the Martin became suddenly easy to handle. It
took the air in but a trifle longer run than a De Haviland. Neither flyer
had his goggles over his eyes. Being seated ahead of the propellers,
that terrific airblast which swirls back from an airplane stick was not
in evidence. The propellers whirred around with their tips less than a
foot from the heads of the airmen.
As soon as he had cleared the last obstacle and had started to
circle the field Jim synchronized the motors until both were turning
exactly fourteen-fifty. He studied gages and adjusted shutters to hold
the temperature steady.
One circle of the field proved that the Martin was all that
Covington said it was. It handled with paradoxical ease—a baby
could have spun the wheel or worked the rudders. Only a slight
logginess when compared with smaller ships would make a pilot
notice what a big ship he was flying.
 Jim was still new enough on Martins to get a kick out of seeing
what he was tooling through the air. The wings stretched solidly to
either side, totalling over seventy feet. Struts, upright and cross,
were like the limbs of some great tree. Four feet to either side of the
cockpit, resting on the lower wing amid a maze of struts and braces,
the Libertys sang their drumming tune.
Broughton swung up the James River and passed between
Petersburg and Richmond. The smiling Virginia country was level
and cleared, and there was nothing to weigh on the flyers’ minds
except what might happen at the end of the flight. Both of them let
their thoughts dwell on what lay ahead. Perhaps Graves’ mind was
running in the same channel, but he was apparently devoting all his
faculties to enjoying the flight. In a Martin the country is spread out
before you—you can watch it as comfortably as from some mountain
peak.

They were flying slightly north-west, and passed Richmond a few

miles to the south. The terrain commenced to become rough and
patchy. Fields were small and clumps of trees studded the ground
thickly. Miles ahead the Appalachian Range loomed majestically. The
altimeter showed six thousand feet, but the Martin would not miss
some of those peaks by a very large margin.
Both Hinkley and Broughton paid increasing attention to the
instruments as the foothills slipped behind, their low green tops
rolling away to the foot of the range. Finally Hinkley held up his wrist-
watch and pointed. It was time for his trick at the wheel. Both men
loosened their belts. Hinkley stood up, took the wheel, and waited for
Broughton to slip into the left-hand seat.
It was not a performance to be essayed by a nervous person. The
ship skidded perilously during the moment when neither man had his
feet on the rudder bar.
Hinkley took up the duty of flying while Broughton began studying
his map. Their course would take them past Lexington, which would
be an easy landmark because of the fact that the campus of the
Virginia Military Institute could be easily picked up. From that time on
careful observation would be necessary, for few landmarks are
available at all, and these few unreliable, when one is well over the
Appalachians.
Lexington slipped by, and the Martin thundered along above a
smiling valley. Hinkley watched the compass like a hawk, striving to
hold exactly to the course they had calculated. Soon they were over
the main range of mountains—for the next hour their only hope lay in
those two mighty Libertys.
It was a scene of breath-taking majesty to look down on the far-
rolling range, the mountain tops of which were less than a thousand
feet below. The bottoms of the ravines, however, were far down, the
infrequent houses as tiny as doll dwellings. The altimeter showed six
thousand feet.
Broughton’s map showed that a small river, winding its way north
and south, should come in sight very soon. By following that river
northward until a railroad that twisted and turned on itself, crossed it,
they would be twenty miles due east of Farran County. When they
reached Farran County they would have to depend on observation to
pick the right place, for only an approximate location was indicated
on the map as Hayden’s headquarters.
As they reached the crossing of the river and the railroad
Broughton leaned over and tapped the motionless Graves on the
shoulder. Graves turned, and Broughton pointed to the map and then
below, indicating the crossing. Graves nodded.
As Hinkley turned due west and they roared toward their goal
Graves studied the faces of his assistants once more. Hinkley’s thin
face was more hawklike than ever below the tight-fitting helmet and
the goggles. The aerial headgear gave him a Mephistophelian
appearance. There was a sort of perverse recklessness graven
there, and not a trace of weakness. Broughton, clear-eyed and
untroubled, seemed to typify quiet capability. Graves turned again to
the primeval grandeur below with a contented smile.
In a moment Broughton and Hinkley changed seats again. It was
more difficult this time, for the scrambled currents of the mountains
were beginning to toss the great bomber around as if it were the
lightest and least stable of scout planes. Masses of cloud above
them made the air more bumpy, as always. The transfer was
accomplished quickly, however, and then all three men began their
difficult search for Hayden’s cabin.
It was almost impossible that they should not be on the course—
at least near enough to be able to see the cabin. Graves took out a
pair of field glasses, and ceaselessly searched the ground below.
One factor made the quest a trifle easier. Not a single mountain did
they see which showed any sign of either clearing or habitation, so
that there was no question, as yet, of making a choice.
It was a strip of country now where five-hundred feet cliffs and
sheer ravines rivaled the majesty of the mountains. Save for the
tremendous trees, in place of the scrubby mesquite, it reminded
Broughton of the mountains around El Paso. To the border flyers
country like that was no novelty. They checked up the maze of
instruments frequently, but aside from that showed no signs of undue
excitement.
Hinkley peered steadily northward for a moment, and then shook
Graves by the shoulder. He pointed to a towering peak, on which a
cleared spot stood out sharply. Before Graves could train his glasses
on it a fleecy cloud blocked his vision. Broughton banked sharply
and skirted the cloud.
Once again the view was clear, and for fully thirty seconds Graves
scrutinized the clearing. Then he motioned Broughton to fly that way.
It was five or six miles away. Four minutes was sufficient to bring
them almost over it. Once again the field-glasses came into play.
Both flyers could see a large timber cabin built a little below the crest
of the clearing, close to the trees. The clearing was on the eastern
slope, including the top and perhaps twenty yards of the western
slope. There did not appear to be ten yards of level earth—the
mountain literally came to a blunt point.
Graves slowly inserted his glasses in his case, and then turned to
the flyers. He nodded briefly, and pointed down.
Jim retarded the spark on the left hand motor, and motioned
Hinkley to turn off the gas line. To do more good, he changed the
altitude adjustment completely. The object of all this was to lean
down the gas mixture in the carburetor.
 Shortly, as the gas had practically run out the motor began to pop
back with loud reports. Hinkley turned the gas on again, and then
Broughton began to click the switches on and off rapidly. It sounded
as though there was a badly missing motor out there on the left wing.
He motioned Hinkley to follow his lead, in order to give himself a
good opportunity to size up the landing situation. He was spiraling
down slowly, with Hinkley seeing to it that the left motor was cutting
out almost completely.

The long way of the clearing was uphill. The lower Broughton
came, the steeper it looked. It appeared to be perhaps two hundred
yards long, narrowing to nearly a point at the peak. The best way to
crack up would undoubtedly be to run up the hill, over the top, and
ram the trees with what little speed was left. There would
undoubtedly be stumps or ditches which would crack them up before
that, but the trees made it a sure thing.
A few men could be seen now, standing around the cabin. Graves
studied them carefully, his glasses out once more. Broughton and
Hinkley were inspecting that clearing, with no time for humans. Jim
handled his great ship in that slow spiral automatically, jockeying the
wheel incessantly as the air currents became worse.
Six hundred feet above the mountain top, he came to a decision.
He could land without cracking up.
Hinkley worked the switches more rapidly, and Jim helped out by
rapid thrusts forward and back with both throttle and spark levers.
Popping, spitting, missing—no one who had ever heard a motor
could believe that the ungodly racket meant anything but a badly
disabled engine.
Broughton spun the wheel rapidly, and turned westward, curving
around until he was headed for the lower corner of the clearing. His
line of flight would carry him diagonally from this corner to a point a
few feet below the peak.
He stalled the Martin as completely as possible. The air-speed
meter showed sixty-five miles an hour. The great weight of the ship
caused it to drop almost as fast as it glided forward.
 The rim of trees formed a barrier nearly sixty feet high. The tail-
skid ripped through them. Jim fought the ship with one hand while he
turned both throttles full on for a moment to stop that mush
downward which was the result of lack of speed.
As he pulled them back Hinkley cut all four switches. Then Jim
banked to the right, so that his wheels would hit the ground together.
He judged it rightly. For a second he thought the ship was going to
turn over on the right, or downhill wing. It seemed to hover on the
verge of it. The pilot snapped on the right-motor switches and the
propeller, turning from the force of the air-stream, caught. The motor
sprang into life as Jim thrust the throttle full on. It swung the right
wing in time, and he cut it as the ship’s nose was turned up hill, both
wheels on the same level. His observation as to the smoothness of
the clearing had been correct. The slightest depression—even a rut
—would have overturned the ship.
Before any one could say anything Jim felt the ship settle
backward. It took a thousand revolutions on the right hand motor to
stop it, but the propeller bit the air in time to prevent the tail-skid
breaking.
“Work the left-hand switches while I taxi up!” yelled Jim into the
pleased Hinkley’s ear.
Graves, his face white but his smile firm, settled back in his seat
as Jim pressed the starter on the left hand motor. It caught.
Several men came running over the brow of the hill as Jim turned
up the left hand motor to equal the right. The thousand revolutions
on the right hand motor had not been sufficient to move and thus
swing the ship, but just enough to hold it steady. It started slowly. As
soon as it had a little momentum Hinkley cut the switches, and at the
same time Jim jerked the throttle back. A loud report, and a brief
miss was the reward of their efforts. Graves looked back approvingly,
and then turned to watch the group of men nearing the plane.
The ship almost stopped, and had started to swing, before the
grinning flyers caught the left hand motor again. Its progress up the
slope was spasmodic, and it would not have been a surety to the
most expert of observers that the left hand motor was not suffering
from a plugged gas line or an intermittent short circuit in the ignition.
With the walking men close alongside, Jim brought the Martin to the
top of the hill. There was just barely clearance enough for the wings.
As soon as the wheels were slightly over the top, enough so that
the Bomber could not roll backwards, he turned off the gas. Soon the
motors began to spit and miss, and then the propellers stopped.
Broughton snapped off the switches.
“Now for the fun,” remarked Larry Hinkley.

V.
It was a miscellaneous collection of men who stood around the
ship. Three of them were very well dressed and looked like business
men. Others, mostly in flannel shirts, were slim, hard-faced,
youngish fellows. Several were foreigners. The rougher-looking
element paid most attention to the great ship, but it was a noticeable
fact that all of them spent more time appraising the flyers than they
did in satisfying their curiosity regarding the bomber.
“How do you do, gentlemen, and just where are we?” inquired
Graves calmly as he removed his coveralls.
There was a few seconds pause as everybody took in his uniform.
It was garnished with several rows of ribbons across the front of the
blouse, the flyers noticed.
“This is in Farran County—nearest town Elm Hill,” returned a
burly, hard-faced man who was wearing a coat over his flannel shirt,
and loosely tied necktie. He was somewhat older than any one else
there except the three men who were dressed so meticulously.
“How far is Elm Hill from here?”
It was Broughton who asked that question.
“Twenty miles. What’s the matter—have trouble?”
It was the hard-faced man again, and he glanced from face to
face quickly as he asked the question. Two of the other men had
walked to the end of a wing, inspecting the ship. The eyes of the
others were constantly flitting from the ship to its passengers, and
they listened closely.
 “Yes. This ⸺ engine here went flooey on us. We’re lucky to get
down alive,” replied Hinkley.
Both flyers were trying to pick Hayden out of the dozen men who
surrounded them, but somehow none of them seemed exactly to fit
their mental pictures of the noted criminal. Several of the crowd were
conversing in low voices.
“Where were you going?” inquired one of the well-dressed men on
the edge of the circle. He was small, wore glasses, and his thin face
had a fox-like look about it that gave him a subtly untrustworthy
appearance.
“Inasmuch as it seems necessary to throw ourselves on your
hospitality for a while, it may be well to introduce ourselves,” Graves
said quietly. In some uncanny way his dignity and competence
seemed to radiate from him, increased by the prestige of his uniform.
Both the airmen felt its influence.
“I am Colonel Graves, of the United States Army Air Service.
These are Lieutenants Broughton and Hinkley. We are flying from
Langham Field, Virginia, to Dayton, Ohio, on important army
business. I trust that we will not trespass on your hospitality too long,
but I fear we will have to dismantle the ship and send it home by rail.
We can’t take off out of this field. We are lucky to have had such an
experienced pilot as Lieutenant Broughton to land us. We did not
expect to find so many people in this deserted place.”
A portly, fleshy-faced man with small eyes set in rolls of fat shoved
his way forward. He had been talking to the fox-faced little man.
“Just a little fishing party up here,” he said with an attempt of
heartiness. He was dressed in a rich-looking brown suit, and a huge
sparkler gleamed from his elaborate silk cravat. He was smoking a
big cigar.
He darted a warning look from his small eyes as two younger,
roughly dressed men in the background allowed their heretofore
guarded voices to become a bit too loud. One man caught the look,
and ceased abruptly.
“It certainly is a good country for it,” replied Graves pleasantly. “I
trust we will not impose on you too much⸺”
 “Not at all, not at all,” the stout man assured him, but the looks of
the others belied his words.
Groups had drawn off a little way and were conversing in
undertones. All the men seemed to have poker faces—there was no
hint of expression in them, although both flyers, as they removed
their coveralls, caught disquieting as well as disquieted looks thrown
their way. Graves continued to converse with the fat man. The tough-
looking customer who had originally joined the conversation stood by
himself, meditatively chewing a blade of grass. His huge right hand,
which had been in his coat pocket at the start, was lifted to his
jutting, prize-fighter’s chin, while his expressionless gray eyes dwelt
steadily on the airmen.
“Quite some ship, eh? It’s a big reskel!” The dialect of a New York
east-side Jew came familiarly to the flyers’ ears. It was a small,
hook-nosed, black-haired man, whose shirt, tie and putteed legs all
gave an impression of personal nicety even here in the wilderness.
His face was somewhat pasty, and his lips very thin. He did not look
over twenty-five.
“It sure is,” Hinkley assured him, throwing both pairs of coveralls
into the cockpit of the ship.
Neither of the flyers wore a blouse, but were arrayed in O. D.
shirts, breeches and boots. Both wore a sagging belt and holster,
with the butt of a Colt .45 protruding from each container. Their garb
and general appearance fitted the wildness of their surroundings
perfectly. Graves had his automatic out of sight, in his pocket. The
sight of the guns the flyers wore caused additional low-voiced
conversation on the part of the onlookers.
The hard-faced American turned and started for the cabin without
a word. Hinkley and Broughton walked over toward Graves.
Every one but the fat man started to walk around the ship,
examining it with interest. Broughton started to walk toward the lower
edge of the clearing. He had an idea that he wanted to verify by
pacing off the distance and examining the rim of trees on the lower
end.
Graves was talking casually to the fat man, describing the flight,
when a loud exclamation and a sudden burst of conversation caused
him to turn. The machine guns had been noted for the first time.
“You fly well armed,” said the tall, stooping Jew nastily. Every one
else was silent, awaiting Graves’ reply.
“The ship is from Langham Field, where all the planes are
equipped for bombing and other tests against battle-ships,” was the
easy reply.
Hinkley, who had been wondering whether Graves would think of
that excuse, smiled admiringly.
“Doesn’t miss many bets,” he told himself. The fat man’s careful
geniality was suddenly gone. While the knot of men who were now
clustered close to the rear cockpit of the ship engaged in further low-
voiced conversation his little eyes roved from nose to tail of the ship,
coming back to rest on Graves’ untroubled face.
The man who had gone to the cabin came back over the hill.
Another man was with him—a powerfully built fellow who towered
over his companion. Every one became suddenly silent, as they
came nearer. Hinkley knew instinctively that this was Hayden.

His deeply lined, somewhat fleshy countenance could have

served as a model for the face of a fallen angel. The wide, cruel
mouth, high forehead and square jaw all indicated strength, and yet
suffering and dissipation were graven there. His eyes, as he
approached the ship, were in direct contrast to the rest of his face.
They were large and bright—the eyes of a dreamer, and they almost
succeeded in counteracting the cruel force of his face. Hinkley had a
glimpse of the man’s magnetism in those eyes.
“How do you do, colonel?” he said quietly.
His voice was deep and rich. He removed the slouch hat he wore,
revealing thick black hair sprinkled with gray. It strengthened the
impression that he had Slav blood in him, for his complexion was
dark and his eyes liquid black.
“We dropped in on you unwillingly, but we are fortunate to find
people here. My name is Graves.”
“I am glad to know you.”
He did not offer his hand, Hinkley noted. He stood quietly, looking
at the ship. Broughton came back at this juncture, his eyes taking in
the massive figure of the newcomer with slow appraisal.
There is an unconscious respect and curiosity engendered in
even the most unemotional person by any man who is noted—or
notorious. A great criminal, a great artist, a champion chess-player,
the survivor of a widely heralded accident—anything unusual draws
its meed of attention. Hayden, without the benefit of his reputation,
was an arresting man. With it, he repaid study.
“I am very sorry, colonel, but we have but little food here—
scarcely enough for our party. I will have some one guide you down
to Elm Hill, where you will be more comfortable,” Hayden said at
length.
“We have a little food in the ship. It’s getting late, and we’ll just
sleep out here under the wings,” returned Graves quietly.
Suddenly a devil peered forth from Hayden’s eyes. The softness
was gone, and savagery was there instead.
Graves looked into that queerly demoniac face without emotion.
Apparently he did not feel the sudden tenseness that had every one
in its grip. All felt the battle of wills going on there—that there was
something underneath which did not appear on the surface.
“I think I’ll turn the ship around and head it into the wind,” came
Broughton’s quiet voice.
It broke the tension. Graves turned to Broughton and Hinkley.
“I think it would be best. We’ll give you a hand on the wing—it’s a
narrow place to turn in,” he remarked casually.
Hinkley primed both motors from underneath, and Broughton got
into the cockpit. As soon as the motors were running Hinkley and
Graves set themselves against the left wing. With the right motor full
on they succeeded in turning the ship until it was headed down the
slope, pointing toward one corner.
“If you don’t turn ’em into the wind the controls are liable to get
flapping,” Hinkley explained to all and sundry. “With a smaller ship,
wind sometimes turns ’em over, getting under the wing, too.”
Larry was wondering whether Broughton was planning to try a
take-off. It looked like suicide to him, but Broughton was the doctor,
Hinkley shrugged his shoulders at his thoughts, and then looked
goodnaturedly at the lowering faces about him. He was enjoying
himself.
Without another word Hayden walked toward the cabin. The
others followed slowly.
“I’ll be back in a moment,” announced the fat man. “If there’s
anything you need⸺”
“Nothing, thank you,” returned Graves.
“We are as welcome as rain at a picnic,” remarked Hinkley after
the man had got out of earshot.
“Just about,” agreed Graves as Broughton returned. “To tell you
the truth, I expected that we would get away with things a lot better
than we seem to be doing. Those three well dressed men are
undoubtedly some of the higher-ups in Hayden’s organization—the
man that went after him is Somers. He is the only one I know.
Somers served ten years in jail for killing a man when he was a
radical leader. It was a strike affair. His specialty used to be salted
mines and that sort of stuff—he’s a rough customer who can take
care of himself. I’m surprized to see him all dressed up out here—if
he’s working the city end of Hayden’s scheme he’s rather out of his
element. We believe he’s the actual leader on the robberies
themselves. That little Jew, Meyer, is the only other man known to
me personally. He’s a New York gangster—good with a gun.”
“How do things look to you?” inquired Broughton.
“The whole bunch is too ⸺ suspicious,”
Graves returned unemotionally. “Part of this gang are simply down
here for a visit, I imagine, to consult with Hayden. He isn’t taking a
chance on getting within miles of a big city policeman. I imagine that
most of the men who do the actual robbing are here, too, hiding out
until the next one is pulled. Probably the prosperous-looking men are
the birds who help get rid of the securities Hayden gets hold of.”
There was silence for a moment. Graves paced up and down
slowly, his head bent in thought.
“I’m going up to the cabin on the excuse of getting some water to
see what I can see. We’ve got to work fast, I can see that. Hayden is
audacious and brilliant, and suspicion is enough for this gang to work
on.”
 “The old boy seems to amount to something, all right,” was
Hinkley’s tribute.
“He is a wonderful man. If he did not have that perverted twist in
him, he might be almost anything. I would suggest that one of you
fool around with this supposedly missing motor, and the other one
walk around and find out as much as possible about the guard
system. We’ve got to be planning how we are going to get out of
here. If you can do it without suspicion, you might see what they
have along that lane there.”

Graves started for the cabin as he finished speaking. Hinkley

strolled carelessly over toward the lane which led away from the
cabin into the woods. Broughton climbed up on the motor with a
wrench in his hand and commenced tinkering with the valves.
The cabin door was open, and Graves could hear a conversation
in which many low-pitched voices took part. He walked in calmly. All
conversation ceased as he entered.
“Could we borrow a pail of some kind and get some drinking
water?” he asked, taking in his surroundings with a single lightning-
like look around.
There were eight bunks, built double-decker, against the four walls
of the cabin. Each was occupied now by a cigaret-smoking man.
Hayden stood in a doorway which apparently led into a small lean-to
at the rear. Somers was sitting on a rude stool. There was one small
table, littered with candle grease and cigaret butts. There was only
one window, close to the ceiling. A sort of half-darkness made it
difficult to make out the features of the men lying on the bunks.
He waited fully a half minute before receiving an answer. Then the
fat man got to his feet.
“I’ll get you one,” he said.
He had darted a quick look at Hayden, Graves noticed, before
saying anything.
He saw nothing but suspicion in the faces of the men about him.
He surmised that few of them lived there, but were there for a
meeting with their chief. Perhaps that might account for their attitude
of extreme suspicion, which did not seem justified under the
circumstances. Then there was always the possibility that some one
of them might know him.
“How long do you think it will be before you get the plane out,
Colonel?”
It was Hayden’s deep, rich voice.
“Several days, I imagine,” returned Graves, watching his man
narrowly.
“I should think that unless your headquarters were notified where
you were⸺”
It was a half question.
“We will wire from Elm Hill tomorrow. If we do not, they will have
forty planes out looking for us,” Graves explained.
He caught several meaning looks passing between various of the
men at his last statement.
“I should think it would be a very difficult job to locate a plane that
was really wrecked in these hills. Of course in your case you’re in a
clearing and it would be easy.”
Hayden’s voice was smooth and his words almost pleasant, but
there was nothing in his eyes now to give the lie to his face. He was
the personification of power and ruthlessness.
Graves’ sixth sense, developed by years of contact with the world
of crime and intrigue, warned him now. His mind probed behind
Hayden’s apparently casual words, and what the government man
thought he found made him look at Hayden with new amazement.
He thought back over the things he knew of the man before him.
For years he had been a thorn in the side of enforcers of the law
all over Europe and America. A dozen times big coups—jewel
robberies, bank robberies, huge swindling schemes—had been laid
at his door, but never yet had he been caught dead to rights because
of his genius for organization and leadership. There was a South
American revolution which star chamber gossip of the secret service
said that Hayden had conceived, promoted, and finally cleared a
hundred thousand dollars on. When supposedly he had left the
country, police and secret service alike had drawn long breaths of
relief.
 There was bigness and sweep about Hayden, and Graves knew
that what he suspected of the man’s plans concerning himself and
the two flyers was by no means too audacious for Hayden to
contemplate. He would order it with no compunction, and it would be
a mere trifle for those men lying around the room to execute.
These thoughts raced through his head as he relighted his cigar.
“Traveling by plane is queer business,” he remarked casually as
he threw the match out the door. “We often have trouble with people,
strange as it may seem. Moonshiners through this state, Tennessee
and Kentucky always think we’re after them if we have a forced
landing anywhere near by. Miners and hill-billys and their sort always
figure army men and an airplane are there for some purpose.
Consequently we always go on a trip well prepared with food, and
heavily armed.”
He watched the effect of his words on his listeners. He was
disappointed. His explanation of the artillery the Martin carried,
besides what he had said about the ship being from Langham Field,
apparently had no effect in lightening the heavy suspicion that he
could feel in the very air about him.
“Well, if you’ll be good enough to give me the pail and show me
where the water is I’ll go back to the food,” he said.
The fat man led him outside and around the corner to a small tent
which sheltered a stove. A plank table with benches was beside it.
A young Italian who appeared to be the cook gave them a pail.
“The spring is right down the path. You can’t miss it,” said the
guide.
His small eyes did not meet Graves’ regard for more than a
second.
The government man got the water and went back to the Martin.
He found Hinkley already there.
“Find out anything?” he asked as he set down the pail.
“There’s a tent and three men on the top of a steep cliff right
above the road. They all seem to be foreigners. And you ought to
see the cliff on the lower side of the road. Anybody that stepped off
that would have time enough to say his prayers and make a will
before he hit bottom. Those three men could hold that road against
an army if they had a machine-gun. I came near getting shot myself.
They said they were camping.”
“It sure looks like a musical comedy war,” remarked Broughton,
sitting cross-legged on the motor.
“There may not be so much comic opera stuff about it, at that,”
stated Graves, removing the cigar from his mouth. “It’s bad.”
He told them briefly of his experience, and then went on:
“The size of the matter is, gentlemen, that those men are up to big
things. They’re so big and Hayden is in such a predicament that in
my opinion he will take no chances. It was only the luck of having an
operative over here who happened to be very familiar with Hayden
that caused us to know he was here. In view of the questions he
asked me about the difficulty of finding a wrecked plane in these
mountains, plus what he is, I believe he plans to kill us, burn the
plane, and then bury the motors or something. I expect that if I am
right it will happen tonight.”
His words were as calm and precise as though he were
discussing the weather. He replaced the cigar in his mouth and
puffed it slowly.
“Somehow or other I can’t believe they would go that far on
suspicion,” said Hinkley. “They⸺”
“Are playing for big stakes, lieutenant,” Graves cut in. “And you
cannot figure them as normal. Somers has killed men—he was in jail
ten years. Hayden would sanction anything necessary for the
success of his project. What are our three lives to them, compared to
the prizes they are playing for, or the results of their being run
down?”
“Lots of people will have seen our ship passing over,” suggested
Broughton. “They may figure that the army will just say another
wreck and let it go, but an investigation might be embarrassing.”
“They could kill us in such a way that it would look like a wreck,”
said Graves. Burn our bodies with the plane, or something like that;”
Both airmen nodded.
“Well, what are you going to do about it?” Hinkley inquired.
“If you’ll pardon me, Mr. Graves, I have a scheme that might
work,” announced Broughton. “It’s no better than a fifty-fifty shot, but