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Dialysis Access
Management

Steven Wu
Sanjeeva Kalva
Harold Park
Chieh Suai Tan
Gerald A. Beathard
Editors
Second Edition

123
Dialysis Access Management
Steven Wu • Sanjeeva Kalva
Harold Park • Chieh Suai Tan
Gerald A. Beathard
Editors

Dialysis Access
Management
Second Edition
Editors
Steven Wu Sanjeeva Kalva
Massachusetts General Hospital Massachusetts General Hospital
Harvard Medical School Harvard Medical School
Boston, MA Boston, MA
USA USA

Harold Park Chieh Suai Tan

University of Texas Southwestern Singapore General Hospital
Medical Center Duke NUS Graduate Medical School
Dallas, TX Singapore
USA Singapore

Gerald A. Beathard
The University of Texas Medical Branch
Galveston, TX
USA

ISBN 978-3-030-52993-2    ISBN 978-3-030-52994-9 (eBook)

https://doi.org/10.1007/978-3-030-52994-9

© Springer Nature Switzerland AG 2015, 2021

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, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents

1 Brief Introduction of Hemodialysis and Vascular Access����������������������   1

Ru Yu Tan and Chieh Suai Tan
2 Angiographic Imaging Equipment����������������������������������������������������������   5
Chieh Suai Tan, Robert M. Sheridan, and Steven Wu
3 Endovascular Tools������������������������������������������������������������������������������������ 15
Chieh Suai Tan, Zubin D. Irani, and Steven Wu
4 Basic Endovascular Skills and Techniques���������������������������������������������� 27
Ru Yu Tan, Chieh Suai Tan, Suvranu Ganguli, Sanjeeva Kalva,
and Steven Wu
5 Radiation Safety ���������������������������������������������������������������������������������������� 37
Patrick D. Sutphin, Steven L. Hsu, and Sanjeeva Kalva
6 Conscious Sedation and Anesthesia Care������������������������������������������������ 51
Lee-Wei Kao, Chieh Suai Tan, and Jason Qu
7 Vascular Anatomy for Hemodialysis Access�������������������������������������������� 63
Shahbaj Ahmad, Chieh Suai Tan, Steven Wu, and Gerald
A. Beathard
8 Hemodialysis Access: Types���������������������������������������������������������������������� 73
Shahbaj Ahmad, Chieh Suai Tan, Robert M. Schainfeld, and
Steven Wu
9 Physical Examination of Dialysis Vascular Access and
Vascular Access Surveillance�������������������������������������������������������������������� 85
Ru Yu Tan, Chieh Suai Tan, David J. R. Steele, and Steven Wu
10 Non-invasive Imaging of Dialysis Access Circuit������������������������������������ 95
Mark Reddick and Sanjeeva Kalva
11 Angiogram and Angioplasty��������������������������������������������������������������������� 115
Suh Chien Pang, Chieh Suai Tan, Steven Wu, and Arif Asif
12 Declotting of Dialysis Vascular Access ���������������������������������������������������� 135
Ru Yu Tan, Chieh Suai Tan, Steven Wu, and Sanjeeva Kalva

v
vi Contents

13 Endovascular Stent Placement ���������������������������������������������������������������� 149

Ru Yu Tan, Chieh Suai Tan, Steven Wu, and Harold Park
14 Minimally Invasive Banding Procedure�������������������������������������������������� 155
Chieh Suai Tan, Zubin D. Irani, and Steven Wu
15 Peripheral Arterial Disease in Hemodialysis Access������������������������������ 165
Akshita S. Pillai, Girish Kumar, and Sanjeeva Kalva
16 Swing Point Stenosis���������������������������������������������������������������������������������� 179
Gerald A. Beathard
17 Thoracic Central Vein Obstruction���������������������������������������������������������� 209
Gerald A. Beathard
18 Vascular Steal �������������������������������������������������������������������������������������������� 243
Gerald A. Beathard
19 Role of Drug-Eluting Balloons in Dialysis Access Interventions ���������� 283
Peiman Habibollahi, Girish Kumar, Dianbo Zhang,
and Harold Park
20 Non-tunneled Hemodialysis Catheter������������������������������������������������������ 293
Suh Chien Pang, Chieh Suai Tan, Anil Agarwal,
and Steven Wu
21 Tunneled Hemodialysis Catheter�������������������������������������������������������������� 301
Suh Chien Pang, Chieh Suai Tan, Steven Wu, and Kenneth D. Abreo
22 Surgical Placement of Hemodialysis Vascular Accesses ������������������������ 323
Shouwen Wang and James F. Markmann
23 Endovascular Creation of Arteriovenous Fistulas���������������������������������� 341
Christine Chen, Marcin Kolber, Ahmed Kamel Abdel Aal,
and Harold Park
24 Surgical Management of Deep Fistula Veins ������������������������������������������ 351
Shouwen Wang
25 Preoperative and Postoperative Care for Hemodialysis
Vascular Access Surgery���������������������������������������������������������������������������� 367
Shouwen Wang and Nahel Elias

Index�������������������������������������������������������������������������������������������������������������������� 383
Brief Introduction of Hemodialysis
and Vascular Access 1
Ru Yu Tan and Chieh Suai Tan

Introduction

Three main treatment options exist to replace the kidney function of patients with
end-stage renal disease (ESRD): hemodialysis (HD), peritoneal dialysis (PD) and
renal transplantation. Hemodialysis is an extracorporeal renal replacement therapy
that uses counter-current dialysate flow across a semipermeable membrane to
achieve uremic toxins and fluid removal. It is now established as a mature therapy
worldwide and has been the mainstay of treatment for ESRD patients. In the United
States, a steady increase in ESRD prevalence was observed between 1980 and 2016,
and the majority of patients used HD as their renal replacement therapy [1].

The First Hemodialysis

The first successful HD was described and performed by Kolff in 1943 [2]. Kolff’s
rotating drum dialyzer was made of cellulose membrane tubes which were filled
with blood and wrapped around a wooden drum that rotated through the dialysate
for removal of uremic toxins during treatment. Since then, the concept was further
refined and improved to provide a safe, reliable and effective therapy for patients
suffering from ESRD. Modern dialyzers are made of more biocompatible or syn-
thetic membranes with clearly defined characteristics and the ability to provide
quantitative clearance of uremic toxins.

R. Y. Tan (*) · C. S. Tan

Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
Duke-NUS Graduate Medical School, Singapore, Singapore
National University of Singapore YLL School of Medicine, Singapore, Singapore
e-mail: tan.ru.yu@singhealth.com.sg; tan.chieh.suai@singhealth.com.sg

© Springer Nature Switzerland AG 2021 1

S. Wu et al. (eds.), Dialysis Access Management,
https://doi.org/10.1007/978-3-030-52994-9_1
2 R. Y. Tan and C. S. Tan

The First Arteriovenous Access

Maintenance HD is only possible in the presence of a vascular access. There are

three main types of vascular accesses used to perform maintenance HD: arteriove-
nous fistula (AVF), arteriovenous graft (AVG) and central venous catheter (CVC).
The initial form of vascular access was called the Scribner shunt. It was implanted
for the first time in a human in 1960 [3]. The surgical technique to create the autog-
enous AVF was described by Brescia and Cimino in 1966. The use of synthetic graft
for arteriovenous (AV) access creation began in the 1970s while hemodialysis cath-
eters started in the 1980s [4, 5].

Trends in Hemodialysis

Hemodialysis is now established as a mature therapy worldwide and has been the
mainstay of treatment for patients with ESRD. In 2017, 86.9% of incident ESRD
patients began renal replacement therapy with HD in the United States. Of all preva-
lent ESRD patients, 62.7% were treated with HD [1].
AVF provides the best outcome when compared to AVG and CVC. Patients with
AVF have the lowest rates of infection, morbidity and mortality. However, the use
of AVF in hemodialysis patients was extremely low in the 1990s. To increase the
appropriate use of AVF, the Fistula First Initiative was started in 2003 [4]. Although
there was a substantial increase in the rate of AVF placement, the primary failure
rates remained high. Driven by the changing demographics in patients with ESRD,
placement of AVF is increasingly challenging as ESRD patients entering dialysis
are older and more likely to suffer from multiple comorbidities including diabetes
mellitus, coronary artery disease and peripheral arterial disease. This highlights the
need to individualize patient care when planning for vascular access placement.
Over the past decade, there has been a growing interest in home HD and inten-
sive HD where patients receive either long-hours nocturnal dialysis or short daily
dialysis. Home HD encourages patients’ independence and allows patients the free-
dom to schedule dialysis at their own convenience. Intensive HD is demonstrated in
many studies to result in a better quality of life, cost-saving in healthcare and better
clinical outcomes [6]. Although home HD was only used by 2% of all prevalent
patients receiving maintenance hemodialysis in 2017, the proportion was increased
by 120% compared to 2007 [1]. A known adverse outcome to more frequent hemo-
dialysis is the competing risks of vascular access-related complications.
Research is currently underway to develop lightweight, easy to use wearable
dialysis devices and implantable hemodialysis devices that would allow patients to
receive dialysis without restricting their daily activities. The successful develop-
ment of these new dialysis devices could potentially improve the outcomes and
quality of life of patients with ESRD. Similarly, improvement in AVF creation tech-
niques and the use of novel devices such as drug-coated balloons for endovascular
intervention are exciting developments in dialysis access management.
1 Brief Introduction of Hemodialysis and Vascular Access 3

References
1. United States Renal Data System. 2018 USRDS annual data report: Epidemiology of kidney
disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases; 2018.
2. Lee WH. A tribute to Willem Johan Kolff, M.D., 1912–2009. J Am Soc Nephrol.
2009;20(5):923–4.
3. Quinton W, Dillard D, Scribner BH. Cannulation of blood vessels for prolonged hemodialysis.
Trans Am Soc Artif Intern Organs. 1960;10(6):104–13.
4. Lok CE. Fistula first initiative: advantages and pitfalls. Clin J Am Soc Nephrol.
2007;2(5):1043–53.
5. Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and
a surgically created arteriovenous fistula. N. Engl. J. Med. 1966:275(20):1089–92.
6. Daugirdas JT, et al. KDOQI clinical practice guideline for hemodialysis adequacy: 2015
update. Am J Kidney Dis. 2015;66(5):884–930.
Angiographic Imaging Equipment
2
Chieh Suai Tan, Robert M. Sheridan, and Steven Wu

Introduction

Since the accidental discovery of X-rays in 1895, technology has evolved so rapidly
that minimally invasive endovascular interventions are routinely performed under
radiological guidance.
Having high-quality fluoroscopic imaging is pivotal for endovascular interven-
tion. Hence, it is essential to know your machine well and understand some of the
common terminologies.

Angiographic Imaging System

Interventional suites may be equipped with either a stationary (Fig. 2.1) or a mobile
fluoroscopic imaging system (Fig. 2.2). The common features of these systems are
the presence of a C-arm, an angiographic procedure table and a console or computer
system to process and project the images for viewing on a screen. As the name sug-
gests, C-arm consists of a C shaped metal mount equipped with an X-ray generator

C. S. Tan (*)
Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
Duke-NUS Graduate Medical School, Singapore, Singapore
National University of Singapore YLL School of Medicine, Singapore, Singapore
e-mail: tan.chieh.suai@singhealth.com.sg
R. M. Sheridan
Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
e-mail: rmsheridan@partners.org
S. Wu
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
e-mail: wu.steven@mgh.harvard.edu

© Springer Nature Switzerland AG 2021 5

S. Wu et al. (eds.), Dialysis Access Management,
https://doi.org/10.1007/978-3-030-52994-9_2
6 C. S. Tan et al.

Fig. 2.1 The layout of an

angiography suite with a
stationary fluoroscopic
imaging system

Fig. 2.2 The portable

C-arm of a mobile
fluoroscopic imaging
system. The radiographer
has to manually position
the C-arm over the area of
intervention

at one end and an X-ray receptor at the opposite end of the C-arm. The patient is
placed on a radiolucent procedure table, between the X-ray tube and the receptor.
A stationary fluoroscopy system consists of a ceiling or floor mounted C-arm,
ceiling mounted monitors and floor mounted procedure table. The entire set up is
fully mechanized and the patient is positioned within the fluoroscopy field by either
moving the motorized procedure table or the C-arm. The stationary system usually
has a larger generator that can provide higher image resolution than a mobile sys-
tem. In addition, the stationary system has excellent C-arm mobility to allow imag-
ing of the target area at different angulations.
2 Angiographic Imaging Equipment 7

A mobile fluoroscopy system consists of a portable C-arm and monitor that can
be moved from room to room. The angiographic procedure table is usually station-
ary and the radiographer manually positions the C-arm over the area of intervention.
They are usually less expensive and have smaller X- ray generators and lower heat
capacity than stationary systems. Some new generation portable C-arm systems can
produce high quality images and have image processing capability similar to that of
the stationary systems.

C-arm

The C-arm consists of an X-ray generator and an X-ray receptor (Fig. 2.3a, b). The
X-ray beam that is generated travels through the patient and is captured by the
receptor, which is either an image intensifier or a digital flat-panel detector. The cur-
rent that is required to generate X-rays is measured in milliampere/second (mAs). It
ranges from 0.5–5 mA for fluoroscopy and is triggered when the fluoroscopy pedal

Fig. 2.3 (a) The generator

is mounted on the lower
a
end of the C-arm and is
located under the table. (b)
The X-ray detector is
mounted on the top end of
the C-arm

b
8 C. S. Tan et al.

is pressed. The current determines the density of the image. Peak kilo-voltage
(kVp), which is a measure of the potential difference across the anode and cathode,
determines the maximum kinetic energy of the X-ray beam. The kinetic energy of
the X-ray beam impacts the penetrability of the X-ray beam and the contrast of the
image. In an automated system, the interaction between the mAs and kVp is deter-
mined by the computer to provide the best image quality at the lowest radiation dose
to the patient.

Foot Switch

A foot switch control is used to start the generation of X-rays by the C-arm (Fig. 2.4).
The pedals are programmed to begin imaging using fluoroscopy or digitally sub-
tracted angiography when depressed respectively. X-rays are generated once the
pedal is depressed and continued until the pedal is released.

Monitor Console

The monitor console usually has two or more computer screens to display the
images (Fig. 2.5). The screen on the left shows the “active” or “live” images, while
the one on the right displays the last recorded image frame or replay the image
sequences.

Fig. 2.4 The pedals on the

foot switch can be
programmed based on user
preference
2 Angiographic Imaging Equipment 9

Fig. 2.5 The monitor

console in a mobile
fluoroscopic imaging
system is mounted on
wheels and can be moved
together with the mobile
C-arm from room to room

Table and Control Panel

The procedure table is made of carbon fiber to allow easy penetration of the X-ray
beam. The stationary system may be equipped with two control panels; one located
at the side of the procedure table, and another may be found within the control room
(Fig. 2.6a–c).

Imaging Options

Pulsed Fluoroscopy

Variable rated pulsed fluoroscopy is an important feature in a digital angiographic

imaging system (Fig. 2.7a, b). In pulsed mode, the X-ray beam is not generated
continuously but delivered intermittently in synchrony with the image display to
produce the appearance of a smooth continuous image. The use of pulsed fluoros-
copy can significantly reduce X-ray dose, but “flickering” of the images can occur
when it is set too low. The default setting in our center is 15 pulses per second
although in general, 4 pulses per second is sufficient for dialysis access intervention.
The X-ray dose at 30 pulses per second is equivalent to that of continuous
fluoroscopy.
10 C. S. Tan et al.

a c

Fig. 2.6 (a) Horizontal movement of the table in all directions is possible once the release knob
is depressed. The three grey colored buttons are used when the restriction in a particular direction
of the table movement is required. (b) This panel controls the generation of images by the C-arm.
Collimation is used to restrict the field of view to the area of interest. Magnification is used to
magnify the area of interest for detailed examination. The images can also be rotated clockwise or
anti-clockwise. (c) This control stick controls the movement of the C-arm. It is used to move the
C-arm around the patient
2 Angiographic Imaging Equipment 11

a d

b e

Fig. 2.7 (a) Fluoroscopy with a “white on black” setting. The angioplasty balloon which is filled
with radiopaque contrast material will appear white. (b) Fluoroscopy with a “black on white” set-
ting. The angioplasty balloon which is filled with radiopaque contrast material will appear black.
(c) In digital subtraction angiography, a “mask” of the area is first created. (d) Using the “mask”
that was initially acquired, background tissues or structures are then digitally removed from the
subsequently acquired images. (e) The injected contrast will appear black on a “white-out” back-
ground that has been digitally subtracted or modified using the “mask” image as the refer-
ence image

Fluoroscopy Versus Digital Subtraction Angiography (DSA)

In standard fluoroscopy, electron dense objects such as bones and iodinated contrast
materials absorb more energy and appear white on a black background. This is usu-
ally reversed digitally such that bone and contrast will appear black on a white
background.
In digital subtraction angiography (DSA), a “mask” of the area of interest is first
taken and used as a reference to digitally remove or subtract the “background” tis-
sues or structures from the images that are subsequently acquired during contrast
material administration. Vessels that are filled with the contrast material appear
black on a “white-out” background. Subtraction angiography improves the contrast
resolution of the images (Fig. 2.7c–e).
Acquisition of DSA images is described in “frames per second”. The image
acquisition frame rate can be adjusted as per the target vasculature. While a slow
acquisition frame rate may not adequately capture the flow of contrast material, a
high frame rate may be unnecessary and may result in a high radiation dose. In
12 C. S. Tan et al.

general, 3 frames per second is sufficient when imaging the central veins (to com-
pensate for chest movement artifact), while 1–2 frames per second is adequate for
peripheral dialysis access interventions.

Collimation versus Magnification

Collimation is used to limit the size of the field of view to the area of interest. It
helps to decrease the radiation dose to the patient and improve image quality by
reducing scattered radiation.
Magnification is used to magnify or enlarge the area of interest. Magnification
results in an increase in the patient’s radiation dose and should be used only when
fine detail is needed.

Optimizing Image Quality

The quality of the images will have an impact on the ability to make an appropriate
interpretation. While obtaining the best image possible is essential, one must be
mindful of the potential adverse effects of radiation. Some of the techniques to
improve image quality are as follows:

1. Minimize the distance between the X-ray detector (image receptor) and the
patient. This improves image quality and decreases scatter radiation.
2. Remove radiopaque objects such as oxygen tubing and ECG leads from the
field of view (Fig. 2.8).

Fig. 2.8 ECG leads

should not be placed
within the
fluoroscopic field
2 Angiographic Imaging Equipment 13

3. Minimize patient’s movements to decrease movement artifacts, e.g., instructing

the patient to breath-hold during imaging of the central veins will improve
image quality.
4. Position the patient and X-ray detector before starting imaging.
5. Keep the area of interest in the center of the image.
6. Use collimation to “remove” unnecessary areas.
7. Use magnification to see details in a specific area when necessary.
8. Increase the number of pulses per second or frames per second where necessary.
9. Use full strength iodinated contrast material rather than diluted contrast mate-
rial, especially when imaging the proximal or central vessels.
10. Oblique views may be necessary to delineate overlapping vessels and detecting
eccentric vascular disease.
Endovascular Tools
3
Chieh Suai Tan, Zubin D. Irani, and Steven Wu

Introduction

The Seldinger technique, first described in 1953, revolutionized the way angiogra-
phy was performed. It overcomes the traditional need for surgical exposure of a
blood vessel before catheterization by using a guidewire to introduce devices into a
blood vessel via a percutaneous puncture. The technique involves percutaneous
puncture of a blood vessel with a hollow needle, introduction of a guidewire through
the needle into the blood vessel lumen, removal of the needle while maintaining the
guidewire in position, followed by advancement of a catheter over the guidewire.
The refinement of this technique by the placement of a sheath over the puncture
site allows devices to be introduced via the same vascular access site without the
need for multiple punctures. The tools for endovascular interventions are outlined in
this chapter.

C. S. Tan (*)
Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
Duke-NUS Graduate Medical School, Singapore, Singapore
National University of Singapore YLL School of Medicine, Singapore, Singapore
e-mail: tan.chieh.suai@singhealth.com.sg
Z. D. Irani
Division of Vascular Imaging and Intervention, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
S. Wu
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
e-mail: wu.steven@mgh.harvard.edu

© Springer Nature Switzerland AG 2021 15

S. Wu et al. (eds.), Dialysis Access Management,
https://doi.org/10.1007/978-3-030-52994-9_3
16 C. S. Tan et al.

Access Needle

All endovascular intervention begins with the insertion of a vascular access needle.
There is a great variety of access needles that can be used. Examples include the
micropuncture needle, introducer needle, sheath needle and angiocath (Fig. 3.1a–c).
Their common feature is the presence of a central channel for the introduction of a
guidewire. The diameter of a needle is described using the stubs iron wire gauge
system in “gauge” or “G”. The maximum guidewire diameter that an 18-G and

Fig. 3.1 (a) An angiocath consists of a hollow core needle with an outer sheath. The “flashback”
chamber allows visualization of blood once the needle punctures the vessel. (b) An 18G cannula
can accommodate a 0.035 in. guidewire while a 21G cannula can accommodate a 0.018 in. guide-
wire. (c) A micropuncture set consists of a micropuncture needle, a guidewire and a transitional
sheath. The transitional sheath consists of an inner 3 Fr sheath and an outer 5 French sheath. The
needle is used to puncture the vessel. The wire is threaded through the needle after a successful
puncture. The needle is then removed, and the sheath inserted over the guidewire. The inner 3 Fr
sheath can accommodate the 0.018 system while the outer 5 Fr sheath is able to accommodate the
0.035 system. The design of the transitional sheath permits upsizing from the 0.018 to 0.035 sys-
tem when required
3 Endovascular Tools 17

21-G needle can accommodate is 0.035 and 0.018 in. respectively. An 18G angio-
cath is routinely used to obtain access to an arteriovenous fistula or a graft in our
institution. A fistulogram or graftogram can also be performed through the 18G
angiocath via injection of contrast material. The 18G cannula can be exchanged for
a vascular sheath over a 0.035 in. guidewire.

Sheath

Sheaths are used to secure the puncture site for vascular intervention. They are plas-
tic tubes that are open on one end and capped with a hemostatic valve at the other
(Fig. 3.2a). The hemostatic valve prevents bleeding and air embolism during the
procedure and allows wires, catheters and other devices to be introduced into the
vessel. The valve end usually has a short sidearm that can be used for flushing, con-
trast material administration and medications.

Fig. 3.2 (a) Components

a
of a vascular sheath. (b) In
general, short sheaths
(4 cm) are used for dialysis
access interventions.
Sheaths are described by
their inner diameters. The
different sheath sizes are
shown here. The 6 F sheath
is frequently used as the
routine sheath for dialysis
access interventions

b
18 C. S. Tan et al.

Sheaths are sized by their inner diameter described using the “French” (Fr) sys-
tem, which is based on “π”. The diameter of the sheath is obtained by dividing the
“Fr” by “π” or approximately 3. For example, a 6-Fr sheath is approximately 2 mm
by the inner diameter. The outer diameter for a sheath is 1.5–2 Fr larger; hence a 6
Fr (2 mm) sheath will create an 8 Fr (2.5 mm) hole in the vessel wall.
The size of the sheath to be inserted is determined by the diameter of the catheter
or angioplasty balloon or device to be used (Fig. 3.2b). The product insert of the
catheter or angioplasty balloon or device will specify the size of the sheath that is
required.
Sheaths also come in different lengths. For AV access interventions, a short
sheath (4 cm) is routinely used. In general, a 4 cm 6 Fr short sheath is often used as
the routine sheath for intervention. The sheath can be “up-sized” over a guidewire
for a larger sheath if a larger angioplasty balloon or stent deployment is required.

Dilator

Dilators are used to enlarge the puncture tract to facilitate the placement of sheaths,
catheters or devices. Dilatation is done by sequentially passing larger dilators over
a guide wire till the tract is adequately sized to accept the intended sheath, catheter
or device (Fig. 3.3). Unlike sheaths that are sized by their inner diameter, dilators
are sized by their outer diameter. Hence, a 7–8 Fr dilator is needed to enlarge the

Fig. 3.3 Dilators come in

different diameters and
lengths. The common
feature is the presence of a
tapered end
3 Endovascular Tools 19

tract for a 6 Fr sheath. In general, sheaths come together with their appropriately
sized dilators in a pack and extra dilators are not required unless you are planning to
upsize the sheath by 2 Fr or more.

Catheter

Similar to dilators, catheters are sized by their outer diameter using the Fr system.
Again, there is a huge variety of catheters available for diagnosis and intervention.
Broadly, catheters can be classified based on their intended use. The material, shape
of the catheter tip, end hole diameter, configuration of side holes (location, size and
number) of each catheter are designed to fulfill its specific purpose.

Non Selective or Flush Catheter

A flush catheter is used for diagnostic angiography. It has an end hole and multiple
smaller side-holes to allow for uniform dispersion of contrast material during
administration. The “pigtail” catheter is a typical flush catheter with a curled tip that
is used for aortography.

Selective Catheter

Selective catheters are used to seek the orifice of vessels and direct guidewire into a
specific location. For this reason, they come in many different shapes. They have
less or no side holes and generally have end hole design for angiography to perform
angiography. The tip of the catheter may be angled like a hockey stick, such as a
Kumpe catheter (Cook Medical, Bloomington, Ind) or have complex curvatures
such as the “Cobra” catheters (Cook Medical, Bloomington, Ind).

Guiding Catheters

These are hybrid between diagnostic catheter and sheath. They are typically used in
place of sheaths to access vessel of interest and to deliver tools for intervention.
They are non-tapered and come in different tip configurations and lengths. Their
French size refers to their outer diameter. Some guiding catheters have special
hydrophilic coatings to enhance the trackability of the catheter over occluded
vessels.
In summary, every catheter has its own unique characteristics and purpose. The
best catheter is one that you are familiar with and is versatile enough to meet your
expectations and requirements most of the time. A 65 cm long 4F Berenstein cath-
eter or Kumpe catheter is routinely used for AV access intervention in our institution
(Fig. 3.4a–d).
20 C. S. Tan et al.

a b

Fig. 3.4 (a) The guidewire repeatedly curled upward while attempting to maneuver it into the
inferior vena cava. (b) A Kumpe catheter was introduced to “stiffen” the wire and exert more con-
trol over its movement. (c) The guidewire was navigated towards the IVC with the aid of the
Kumpe catheter. (d) The guidewire finally passed into the inferior vena cava

Guidewire

Guidewires come in different thicknesses, lengths, stiffness, coating and tip con-
figurations (Fig. 3.5). The diameters of a guidewire are measured in inches and
are available in sizes ranging from 0.008 to 0.038 in.. The common sizes in
everyday use are the 0.018 and 0.035 in. wires. Guidewires may have a
3 Endovascular Tools 21

c d

Fig. 3.4 (continued)

hydrophilic coating to enhance their maneuverability. The hydrophilic or “water

seeking” coating enables the wire to be advanced easily within the vessels.
Hydrophilic wires with steerable or angled tip designs are especially useful in
crossing critically stenotic lesions. However, the hydrophilic coating makes the
wire feel slippery and can give an impression of movement when it is stationary.
A 180 cm 0.035 in. regular angled tip hydrophilic wire is routinely used for
dialysis access intervention in our institution.
22 C. S. Tan et al.

Fig. 3.5 Guidewires can

come in different lengths,
tip designs and coating

Balloon Catheter

There are two basic types of balloons. A non-compliant balloon is used for angio-
plasty while a compliant balloon (e.g. Fogarty balloon) is used for embolectomy or
temporary vascular occlusion. These balloons are mounted on catheters and the
shaft of the balloon catheter is described using the Fr system (Fig. 3.6a–g) and the
length of the shaft in centimeters.
The size of the balloon, on the other hand, is described by its diameter in milli-
meters when inflated; followed by its length in centimeters. For example, an “8 by
4” balloon has an 8 mm diameter and a 4 cm length when inflated and may be
mounted on a 5 Fr shaft. The balloon is tightly wrapped around the balloon catheter
before inflation. After use, the deflated balloon will not return to its original size and
can be larger in diameter than the shaft that it is mounted on. As such, an 8 mm bal-
loon that is mounted on a 5 Fr balloon catheter will require a 6 Fr sheath to permit
smooth removal of the balloon catheter. The size of the sheath required to permit the
passage of the balloon catheter is usually described in the product insert.
A “cutting” or “scoring” balloon is a non-compliant balloon with atherotomes or
blades mounted on its surface to “cut” or “score” the stenotic lesion during inflation.
It is useful in the treatment of stenotic lesions that are resistant to balloon angioplasty.
The angioplasty balloons that are used for dialysis access intervention are usu-
ally non-compliant and can be inflated to “high pressure”. It is important to know
the nominal pressure and the rated burst pressure of the balloon when performing an
angioplasty procedure. These pressures are usually indicated on the product insert
of the angioplasty balloon. The nominal pressure is the inflation pressure at which
the stated diameter of an angioplasty balloon is achieved. The rated burst pressure
(RBP) is the pressure at which 99.9% of balloons can maximally withstand before
rupture with 95% confidence. It is advisable not to inflate beyond the rated burst
pressure as rupture of the angioplasty balloon can result in embolism of the balloon
fragments and retrieval of a ruptured balloon may be difficult.
3 Endovascular Tools 23

a b

f
c
g

Fig. 3.6 (a) Components of an angioplasty balloon catheter. This is an example of a high pressure,
non-compliant balloon. (b) The size of an angioplasty balloon is described by its diameter in mil-
limeters when inflated; follow by its length in centimeters. The balloon is mounted on the tip of a
catheter. (c) Radiopaque markers are present to mark the position of the balloon during fluoros-
copy. (d) The characteristics of the angioplasty balloon catheters are described in the product
insert. Information on the recommended sheath size, guidewire and rated burst pressure of the
balloon is indicated. (e) The nominal pressure and rated burst pressure are usually indicated in the
product insert. The nominal pressure is the inflation pressure at which the stated diameter of an
angioplasty balloon is achieved. The rated burst pressure (RBP) is the pressure at which 99.9% of
balloons can maximally withstand before rupture with 95% confidence. (f) The deflated angio-
plasty balloon will not return to its pre-inflated size after being used and is bigger than the diameter
of the balloon catheter that it is mounted on. Therefore, even though it is mounted on a 5 Fr balloon
catheter, a 6 F sheath is required to permit smooth removal of the entire balloon catheter after use.
(g) The Fogarty balloon (Edwards Lifesciences, Irvine, CA) is an example of a low pressure, com-
pliant balloon
24 C. S. Tan et al.

The angioplasty balloon can be inflated either using an inflation device or a

syringe assembly. The inflation device looks like a huge syringe with an attached
manometer. It has a locking mechanism to maintain pressure and allow inflation of
an angioplasty balloon to a precise pressure. These devices are designed for one-­
time use and may be costly. An alternative is to manually inflate the balloon using a
syringe assembly consisting of a 3 and 10 mL syringe connected via a 3-way stop-
cock. The balloon is first inflated using the 10 mL syringe. The 3-way stopcock is
then turned and pressure is maintained using the 3 mL syringe. The pressure should
be maintained for approximately 3 min to ensure adequate dilatation and effacement
of the stenosis.

Stents

Stents are broadly classified into balloon-expandable or self-expanding balloon

stents. Balloon expandable stents require balloon dilatation to increase their diam-
eter from the compressed state. They have greater radial strength and can be over
dilated but they will not return to their deployed shape when crushed or compressed;
hence they are less suitable to be used in peripheral vessels in the limbs. However,
they are preferred when accurate positioning of the stent is of paramount impor-
tance. One such example is during the treatment of subclavian artery ostial stenosis,
where the stent has to be positioned accurately across the stenosis with minimal
protrusion of the stent into the aortic lumen. Self-expanding stents will conform to
the vessel wall and expand to its designed diameter. They have greater flexibility
and will return to the original shape after bending or compression.
The flexibility and strength of a stent are dependent on the construction material,
design and configuration of its “cells”. A stent is made up of multiple cells that are
connected by struts. A closed-cell design is one where struts support every cell. In
comparison, in a stent with open-cell design, some cells are not in contact with any
struts at all. By varying the cell designs and number of struts, the flexibility and
radial strength of a stent can be altered.
Stents can be constructed with stainless steel or alloys such as Nitinol and Elgiloy
(Fig. 3.7a). Nitinol exhibits shape memory, allowing it to regain its shape after com-
pression. Stents that are constructed using Nitinol provide better long-term patency
compared with stainless steel stents in the treatment of hemodialysis graft related
stenosis [1].
Stents may also be “bare” or “covered” with relatively inert polymeric covering
such as expanded polytetrafluoroethylene (PTFE) (Fig. 3.7b). The intention of the
covering is to decrease the high restenosis rates associated with bare-metal stents that
are caused by neointimal hyperplasia. The covering is postulated to work by providing
a barrier to prevent the migration of smooth muscle cells and separate the thrombo-
genic wall surfaces from the luminal blood flow. The characteristics of the four types
of self-expanding covered stents that are available in the United States are summa-
rized in Table 3.1 [2]. Covera and viabahn stents are approved by the FDA for the
treatment of venous anastomotic stenosis in arteriovenous grafts.
3 Endovascular Tools 25

Fig. 3.7 (a) Bare nitinol

stents exhibit great a
flexibility and return to
their original shape after
compression. (b) Different
types of stents

Table 3.1 Types of stents used in dialysis vascular access intervention

Name of stents Wallgraft Viabahn Fluency plus Covera
Stent material Elgiloy Nitinol Nitinol Nitinol
Covering Polyethylene Expanded Expanded PTFE Expanded
terephthalate PTFE PTFE
Characteristics Relatively rigid Very flexible Stiffer than Very flexible,
with poor Viabahn available in
contourability a straight or
flared
configuration

References
1. Kakisi JD, Averinos E, Giannakopoulos T, et al. Balloon angioplasty vs nitinol stent placement
in the treatment of venous anastomotic stenoses of hemodialysis grafts after surgical thrombec-
tomy. J Vasc Surg. 2012;55:472–8.
2. Penden EK. Role of stent graft for the treatment of failing hemodialysis accesses. Semin Vasc
Surg. 2011;24:119–27.
Another random document with
no related content on Scribd:
CHAPTER XXIX. HOW TO MAKE A
THIRD GILDING COLOUR FOR
VERY THICK GILDING. [181]

Take the work you want to gild, & in the same way as described
above, clean it[182] and gild it, then skilfully dry it; don’t be particular
as to drying it too much, only let it be free of all quicksilver, then
clean it again lightly and heat it over live embers. Whilst it is in
process of heating spread on it a kind of wax which I will describe
below.
When the wax is spread, let the work cool, then have a fire ready of
such nature as shall melt off the wax without heating the metal to
redness. When heated in this way, rinse it out in a solution of tartar
and water—what among goldsmiths is called grommata. This done,
let it stand for such time as you can say an Ave Maria, then clean it
with a brush in fresh water, rubbing it well.[183] If your work has been
well gilded, you may further colour it with the process I shall tell you
of shortly. But as to do so you have first to wax it, I had best tell you
to begin with how that wax is made; and ’tis in this wise.

FOOTNOTES:

[181] Che sia abbondantemente carico d’oro.

[182] Cellini refers to the preliminary cleaning with urine described
in Chapter xxvii.
[183] Ristiara di buon vantaggio.
CHAPTER XXX. HOW TO MAKE
THE WAX FOR GILDING.
Take five ounces of new wax, half an ounce of red chalk (that is to
say, red stone chalk for drawing[184]), half an ounce of Roman vitriol,
[185]
three pennyweights[186] of feretto di spagna,[187] that is of the
weight of a ducat, or one-eighth of an ounce, or it may be a bit less,
half an ounce of verdigris, & three pennyweights of borax. Mix all
these things together and melt them with the wax, & apply them as
above described. After this, when the wax is cleaned off, you can
give it the colouring that follows hereunder.

FOOTNOTES:

[184] Lapis rosso da disegnare; French, ‘sanguine.’

[185] Vitriouolo romano: sulphate of iron.
[186] Denari.
[187] Possibly calcined sulphate of iron; French, ‘ferret.’
CHAPTER XXXI. HOW TO MAKE
YET ANOTHER COLOURING.
Take half an ounce of Roman vitriol, half an ounce of saltpetre, six
pennyweights of salts of ammonia, half an ounce of verdigris, and
pound them upon a stone, do not use iron. Pound the salts of
ammonia first very carefully, then all the others together. Then mix
them in a glazed vessel[188] with as much water as shall make them
have the consistency of a sauce, stir them over the fire with a piece
of wood, & let them boil for such space as you can say two
Paternosters. Do not give them a strong fire for that would spoil
them. Everything in moderation. Let them cool, and use them as is
here written in the manner following.

FOOTNOTES:

[188] Pentolino.
CHAPTER XXXII. THE MANNER OF
APPLYING THE SAID COLOUR.
Let your work be dried with a clean cloth, then by means of a few
feathers streak it over with the above concoction in the same way as
you did when colouring the gold with the verdigris mixture. Then put
it on the fire. When you see it drying and beginning to steam hard
(do not let it steam quite dry) dip it in cold water. Then clean it up, &
once again let it simmer slowly in the tartar solution[189] for such
space as you may say an Ave Maria; yet again clean it in water and
polish it where you will. This gives the loveliest gilding and of the
most beautiful colour that can be made, and lasts for ever.

FOOTNOTES:

[189] Bollire freddo nella grommata.

CHAPTER XXXIII. WHAT YOU DO
WHEN YOU WISH TO LEAVE
BARE THE SILVER IN CERTAIN
PLACES.
When you have cleaned up the parts where the gold is not to stick,
you take some flour dust, such as you may gather on the walls and
cornices of mills, & we in Florence call fuscello, and you mix it with
water to the consistency of a paste, and with a (camel’s) hair brush
lay it thick on the parts not to be gilded, after which you dry it well
before a slow fire, and can gild safely.
Another way, too, may be employed where the flour dust is not used.
You take gesso in the cake,[190] such as the shoemakers use, pound
it up well, and make a paste of it either with stag glue,[191] or better
with fish glue,[192] but mind that either glue be well mixed with water,
so that it does not get too stiff. And inasmuch as I want to omit
nothing, I bid you note that this gesso is best employed when you
merely want to gild and leave the silver white, whereas the flour dust
method is best used when you want in addition to colour the gold as
above described. This is as much as you need know about such
matters.
Now though, of a truth, the prime merit of every craft is your being
well able to practise it yourself, yet none the less it were better to
leave these processes of gilding to those who are specialists, for it is
as I said very unhealthy[193] to practise. Know how it’s done, that’s all.

FOOTNOTES:

[190] Gesso in pane.

[191] Colla cervona. Probably a glue made of stags’ skins or
chippings. In ‘Cennino Cennini’ is a footnote on glues, quoting
from ‘Dioscorides’ a glue, colla taurina, hence possibly ‘cervona’
from ‘cervo.’
[192] Colla di pesce.
[193] Perniziossima.
CHAPTER XXXIV. HOW TO MAKE
TWO KINDS OF AQUAFORTIS,
ONE FOR PARTING, THE OTHER [194]

FOR ENGRAVING & ETCHING.

First I will talk of that mixture with which you etch on copper instead
of cutting with the graver, this is an easy and a very beautiful
method. Aquafortis for etching is made thus: you take half an ounce
of sublimate,[195] one ounce of vitriol, half an ounce of rock alum,[196]
half an ounce of verdigris, and six lemons; and after having care to
pound the first mentioned substances well, you boil them a little in
the lemon juice, but not so as to let them get too dry. The boiling
should be done in a glazed pot, and if you have no lemons you may
take strong vinegar which will give a like result. When you have well
smoothed your copper plate you can take any ordinary varnish,[197]
such as is used for the lacquering of the ornaments on daggers and
other iron work, & heat it gently, putting a little wax with it, this you do
to prevent the varnish from cracking when you draw upon it. It must
not be too hot when you spread it on your copper plate. When you
have etched on your design make a ridge of wax round the plate and
pour on the parting water, letting it stand not longer than half an hour.
If then it be not bitten deep enough, do it again. Then remove it and
clean it well with a sponge. You draw on the varnish with a stylus of
well tempered steel, that is an iron needle, which in the craft is
termed a stile. You wash the varnish off the plate with a sponge of
warm oil, but very softly so as not to destroy the intaglio. Then you
use the plate & stamp impressions on to card-board from it in just
such a manner as plates done with the graver. It is true that this sort
of plate is produced very easily, but then, you see, they don’t last
near so long as those done with the graver.
FOOTNOTES:

[194] Acqua da partire is the acid into which you put alloys and
clippings, filings, etc., to separate gold from silver, or silver from
copper, or gold from gilt copper, in other words nitric acid.
Partitore is the man who exercises this trade. Hoepli’s Manual,
‘Oreficeria,’ published Milan, gives information about the modern
way of using acids for ‘separating or parting.’
[195] Solimato: can this be sublimed sal ammoniac?
[196] Allumi di rôcca.
[197] Vernice ordinaria.
CHAPTER XXXV. HOW TO MAKE
AQUAFORTIS FOR PARTING.
Aquafortis for parting[198] is made thus. You take 8 lbs. of burnt rock
alum[199] & an equal quantity of the best saltpetre, and 4 lbs. of
Roman vitriol, & put them altogether into the alembic,[200] add to
these things a little aquafortis that has already been used, exercising
your discretion as to the quantity. And in order to give a good
luting[201] to your alembic take horse-dung, iron filings & brick dust in
equal proportions, and mix them up with the yolk of a hen’s egg, then
smear the mixture over the alembic as far as the furnace will allow.
Then for the rest put it to a moderate fire, as the wont is.

FOOTNOTES:

[198] Partire.
[199] Allume di rôcca arso. Prof. Church tells me that this is
probably sulphate of alumina, from alum shale.
[200] Boccia. Biringoccio in the fourth book of his ‘Pirotechnica,’
Venice, 1540, Chap. I., gives an illustrated description both of
such an alembic and of how aquafortis for parting is distilled. See
also the French edition of the same book translated by ‘Jaques
Vincent.’ Rouen, 1627.
[201] Loto: the closing of the joints.
CHAPTER XXXVI. HOW TO MAKE
ROYAL CEMENT.
Take the gold you wish to refine and beat it thin, cut it into little
pieces of the size and the thickness of a golden scudo. Sometimes
the scudi themselves are taken and a twenty-four carat cement
refined direct from them; and this simple[202] cement has such virtue
that it can draw all the alloy[203] out of the scudo itself without
destroying the impression on the coin, but drawing from it only what
was of base metal.
The cement is made in this wise: Take tartar and brick dust and
make a paste of them; construct a round furnace[204], & into the joints
of the furnace between one brick and another spread the paste; put
your pieces of gold, or the scudi themselves, if you use them, into
the paste, and cover them well up with more of it; then fire for
twenty-four hours, at the end of which time they will be refined to
twenty-four carats.[205]
Know, gentle reader, that this screed of mine is not writ for the
purpose of teaching such as are refiners[206] by profession how to
make aquafortis, my only care is to show how & to what end it may
serve the art of goldsmithing; for it came about that having made
certain golden figures half a cubit high for King Francis, when they
were near the ending, during the softening in the fire, it happened
they got a film of lead fumes across them, and had I not covered
them over with this cement lotion they would have gone brittle as
glass.[207] Then I gave them six hours moderate firing, and so in this
way freed them from so evil a blemish.

THE END OF THE TREATISE ON GOLDSMITHING.

FOOTNOTES:
[202] Cellini may intend a stronger sense to the word ‘semplice.’
[203] Lega.
[204] See above, furnace construction.
[205] Cellini appears not to have quite understood the process.
Geber, who gives the oldest description of it, ‘Alchemiae Gebri
Arabis Philosophi Solertissimi Libri, etc. Joa͠ n: Petreius
Nuremberge͠ n denuo Bernae excudi faciebat,’ anno 1545, p. 51,
gives the ingredients thus: ‘Vitriol (ferrous sulphate), sal
ammoniac, flower of copper (scale of oxide of copper formed by
heating the metal with access of air), ground old earthen pot,
sulphur in the smallest quantity or none at all, man’s urine,
together with similar sharp and penetrating substances,’ etc. See
Percy’s ‘Metallurgy,’ Murray, 1880; Part I., p. 385. Prof. Roberts-
Austen adds that ‘usually the “cement,” and the gold to be
purified, were placed together into a porous earthen pot, and not
between the joints of the brickwork.’
[206] Partitore.
[207] I am assured that this is a point of considerable scientific
interest.
THE TREATISE ON
SCULPTURE.
The Nymph of Fontainebleau
THE TREATISE ON SCULPTURE.

CHAPTER I. ON THE ART OF

CASTING IN BRONZE.
As in other places I have done, so now will I do afresh, & in order to
give more surety & confidence to him that reads this screed of mine,
adduce examples from sundry great works in bronze that I made for
King Francis while in the glorious city of Paris. Those bronzes in part
I finished, the greater part I left imperfect. One of the completed ones
was a lunette about eight cubits across, made for the gateway of
Fontainebleau. For this arch I fashioned a statue about seven cubits
long in rather more than half relief, it was a figure personifying the
fountain. Under its left arm were vases, from which water seemed to
flow, and its right arm was posed upon the head of a stag, a great
part of whose neck was brought out in full relief. On one side of the
lunette were a number of dogs, that is to say setters [208] &
greyhounds; on the other side were fashioned stags and wild boar.
Above the lunette I made two little angels with torches in their hands
as signifying victory, & over the whole was the salamander, the
emblem of the King. There was abundance of rich festoonment, and
two great satyrs for the pilasters of the gate. These latter were not
cast, but were left in a state ready for casting. The lunette, however,
was cast in several pieces, & the first and biggest was the nymph of
Fontainebleau herself.[209] Her head & other portions of her body
stood out in full relief, while the rest were in half relief. The way I
fashioned her was as follows. I made a model in clay of just the size
the figure was to be; this done, I estimated that the shrinkage would
be about one finger’s thickness. So I very carefully went over the
whole, touching it up and measuring it as the art directs.[210] Then I
gave it a good baking, and after that I spread over the whole an even
coat[211] of wax of less than a finger’s thickness, similarly adding wax
where I thought it needed it, or even taking a little away from off the
waxen coat that was over the whole. This method I pursued till I had
completed it with infinite diligence and care.
After this I pounded up some ox bone, or rather the burnt core of ox
horns. It is like a sponge, ignites easily, and is the best bone that you
can get anywhere. With this I beat up half a similar quantity of gesso
of tripoli,[212] and a fourth part of iron filings, & mixed the three things
well together with a moist solution of dung of horses or kine, which I
first passed through a fine sieve with fresh water, till the latter took
the colour of the dung.
The whole formed a composition which I applied to my model with
hog sables, arranging the bristles so that their softer and external
ends formed the end of the sable, and were thus tenderer to work
with; and so gave the whole figure an equal coating of the
composition all over, then I let it dry, and similarly gave it two more
coats, each time letting them dry. These coats were every one about
the thickness of an ordinary table knife’s back. This done, I gave it a
coat[213] of clay about half a finger thick, let it dry, gave it another coat
about a finger thick, let that dry too, and finally gave it a third, of the
same thickness.

FOOTNOTES:

[208] Bracchi.
[209] See Cellini’s allusion to this in the ‘Vita.’
[210] Misurando come prometta l’arte.
[211] I interpret this to mean that he made measurements with a
view to regulating the subsequent wax coat which was in the end
to be replaced by the bronze. Brinckman interprets it otherwise;
according to him the meaning would be that because of the
shrinkage Cellini gave the figure another coat of clay, but this
appears to me to imply a misunderstanding of the process. See
also, Symonds’ interpretation of this method in the ‘Vita.’
[212] Gesso di tripolo.
[213] Camicia.
CHAPTER II. HOW THE ABOVE-
MENTIONED CLAY IS MADE.
The clay you use is made thus: You take such clay as is used by the
ordnance makers for their moulds. It may be found in many places,
but preferably near by rivers, for there it has a certain sandiness,[214]
still it must not be too sandy, suffice it if it be thin, for the rich clay is
delicate and soft, such as is used for small figures, cups, plates, and
so forth, but not good for our purpose. Also you will find it in hills and
grottoes, particularly round Rome and Florence, and in France at
Paris. The clay from the latter city is the finest I ever saw; but as a
rule the clay from grottoes is better than that from rivers.
In order to obtain a good result you must let it dry, and sift it carefully
through a rather coarse sieve in order to get rid of any pebbles or
bits of root or of glass, & such-like things. Then you mix it with cloth
frayings, about half as much of the latter as you have clay; and take
note that here is a wondrous mystery of the craft that has never yet
been used by any but me. When the clay and the cloth frayings are
mixed and bathed with water to the consistency of a dough, you beat
the mixture up well with a stout iron rod about two fingers thick; and,
for this is the secret, you let it decompose for at least four months or
more, the longer the better; for then the cloth frayings rot, and owing
to this the clay gets to be like an unguent. To those who have not
had experience of this little trade secret of mine the clay will appear
too fatty, but this particular kind of fattiness in no wise hinders the
accepting of the metal,[215] indeed it accepts it infinitely better, & the
clay holds a hundred times more firmly so than if it had not rotted. I
have used this kind of clay in ever so many most difficult works, all of
which I shall tell of in their proper place.

FOOTNOTES:
[214] Alquanto renosa.
[215] Lo accettare il metallo.
CHAPTER III. ANOTHER METHOD
OF CASTING FIGURES IN
BRONZE OF LIFE SIZE OR A
LITTLE UNDER.
Model the figure you wish to cast direct in the clay and rag
composition above described. Finish your model most carefully as
regards its proportions and its details of design, in fact just as you
wish to see it completed. When you have finished your figure,
working it part in the fresh & part in the dry clay, as the art may
require, and wishing to cast it in bronze, you give it a covering of
painter’s foil[216] in order to do which you first take a certain quantity
of turps, heat it in a cauldron or pail, and when it is heated to boiling,
streak it very carefully all over the figure with a hog’s sable, taking
heed not to injure a single muscle, vein or other subtlety, and so very
carefully apply your foil. This foil has to be beaten into very fine
sheets such as the painters use in many places, as for instance on
their canvasses for painting coats of arms; it is well enough known
all the world over. Well, you put this foil over the clay figure, and as
you have to make a mould of gesso over that, you oil the whole
figure well first. Were it not for the foil it would be but ill protected
against the humidity and cohesive[217] power of the gesso, but with
the foil it is well protected. In this way you work to great advantage,
for after the figure is cast in bronze you still have your fine original
model before you; and many youths & able workmen can help you
clean the bronze figure up, while if you have no model to work to,
this cleaning up takes a long time, is little to the poor master’s liking,
and has but a sorry result. This was what happened to me when I
made the Perseus for the most illustrious Duke Cosimo, and which
may still be seen on his Excellency’s piazza. This, which was a
figure of more than five cubits high, was made in the first of the two
described methods; that is to say, it was modelled in the clay
composition, & finished one finger’s thickness under actual size;[218]
then it was well baked, and the coat of wax modelled over it as in the
case of the nymph of Fontainebleau. After this it was cast all in one
piece. In order to remove the core[219] so that the figure might be
lighter, I made through the wax a number of holes in the flanks,
shoulders, and legs, and at such places where I required them; the
result of this was that the core was kept in its place. Moreover, I put
over the wax those unguents which I referred to in the case of the
nymph of Fontainebleau, then the two or three coats of clay, next I
bound it round with the iron of which I shall tell directly, & then I cast
it. This casting was, owing to its size, the most difficult casting ever
made. But because I am now minded to tell of the casting of a
smaller figure, I will not muddle things too much by leaving my
theme. Later on I shall not fail to enter upon a little dissertation about
my Perseus.