Abstract:
The invention is a device and corresponding method for the rotatable selection, preparation and recollection of hemodialysis cannulation sites along a surgically constructed arterio-venous fistula or arterio-venous graft of a patient with end-stage renal disease. The device comprises a program, a site preparation card, transparent dressings held in a dressing folder; transferably detachable self-adhesive mnemonic markers, and a skin marking device. The program has means for removably receiving the site preparation card, the transparent dressings held in the dressing folder, and the detachable self-adhesive mnemonic marker. The skin marking device has means for removably attaching to the program. The method utilizes a system of instruction and interaction with the device to enable the patient to rotatably select, prepare and recall hemodialysis cannulation sites along the patient&#39;s arterio-venous fistula or arterio-venous graft, thereby minimizing trauma, infection and pain, and also maximizing the longevity of the arterio-venous fistula or arterio-venous graft.

Description:
BACKGROUND OF THE INVENTION  
       [0001]     1. Technical Field  
         [0002]     The present invention relates generally to the treatment of end-stage renal disease and, in particular, to the minimization of trauma, infection and pain in patients undergoing hemodialysis and the extension of the longevity of surgical arterio-venous grafts and fistulas used in hemodialysis.  
         [0003]     2. Related Art  
         [0004]     Hemodialysis is a recurrent chronic treatment indicated for patients with end-stage renal disease (“ESRD”), in which blood is circulated outside of the body of an ESRD patient and through a hemodialyzer for the removal of urea and other molecular and electrolytic blood-borne waste products. In patients with ESRD, hemodialysis is performed about three times a week, with each treatment lasting 3 to 4 hours.  
         [0005]     Blood flow rates of about 300 to 400 L/min are necessary for hemodialysis. Venous blood flow is insufficiently slow, and repeated puncture of a large artery is not medically feasible. Consequently, prior to undergoing hemodialysis, a patient with ESRD must have a high-flow arterio-venous (“AV”) access site (hereinafter “hemodialysis access configuration”) surgically constructed, along which, at hemodialysis cannulation sites, paired arterial and venous needles are inserted for withdrawing toxin-laden blood and returning freshly-dialyzed blood.  
         [0006]     The preferred method for securing high-flow access to a patient&#39;s circulation for hemodialysis is through a surgically created AV fistula (“AVF”), which is often made at the wrist between the radial artery and cephalic vein, or at the elbow between the brachial artery and the basilic vein. If a native vein is unavailable because of fibrosis or atrophy due to prior needling, phlebitis or other injury, a prosthetic vascular graft bridging an artery and a nearby vein (hereinafter an “AVG”) may be utilized. The AVG is generally made of polytetrafluoroethylene. The AVG is commonly either a straight AVG (“SAVG”) or a looped AVG (“LAVG)  
         [0007]     Unfortunately, thrombosis, infection and aneurysm formation commonly occur in AVGs and comprise the leading cause of hospital admission in patients with ESRD. There is also a high incidence of septicemia and septic embolization associated with AVG infections. Despite these disadvantages, AVGs are currently the most common way of achieving access to the circulation of an ESRD patient for hemodialysis.  
         [0008]     A dialysis treatment occurs over 3 to 4 hours and is generally repeated 3 times a week, typically on either a Monday-Wednesday-Friday schedule or a Tuesday-Thursday-Saturday schedule. At the commencement of each hemodialysis treatment, an efferent needle is inserted into the arterial aspect of the AVG, and an afferent needle is inserted into the venous aspect of the AVG. The efferent needle is connected to tubing that draws blood into the hemodialyzer from the ESRD patient and the afferent needle is connected to tubing that returns blood from the hemodialyzer to the ESRD patient.  
         [0009]     After each hemodialysis treatment the needles are withdrawn and a pressure bandage is placed on access/cannulation site. Thereafter, additional gauze is applied to the wound under pressure until bleeding stops. Cessation of bleeding takes about 10 to 20 minutes, at which point the blood-soaked gauze is removed and the wound site is dressed with fresh gauze that is secured by a sure seal band-aid. The patient may then return home. The gauze dressing may be removed several hours after its application, but the sure seal band-aid may be left in place for as long as 8 hours.  
         [0010]     The current procedures for preparing an ESRD patient for a hemodialysis treatment omit steps to avoid piercing the same area of a patient&#39;s skin before the wounds made by prior piercing to obtain AV access have healed. This omission results in increased cutaneous, subcutaneous and vascular trauma and increased pain.  
         [0011]     Chronic repeated insertion of these needles eventuates in traumatic breakdown of the skin, and traumatic breakdown and stenosis of the graft site, particularly in the vicinity of its venous anastomosis. Traumatic breakdown and stenosis requires thrombectomies, AVG salvage, surgical revision procedures and new surgical constructions. AVG life may be prolonged with patch angioplasty at venous outflow stenoses or by adding a new segment of PTFE to bypass areas of venous stenosis.  
         [0012]     ESRD patients are also at risk for infection, which is second only to cardiovascular disease as a cause of death in these patients. AVGs have been identified as a major risk factor for septicemia and complications such as endocarditis and septic arthritis in patients undergoing hemodialysis.  
         [0013]     Accordingly there is a need for systems and methods that: minimize cutaneous, subcutaneous and vascular trauma; minimize the risk of cutaneous, subcutaneous, vascular and systemic infection; minimize pain; and maximize the functional integrity and longevity of AVGs.  
       SUMMARY OF THE INVENTION  
       [0014]     The invention is a device and method for the rotatable selection, preparation and recollection of hemodialysis cannulation sites along a hemodialysis access configuration of a patient with ESRD, comprising: a program having an inner face and an outer face; a site preparation card; at least two transparent dressing held in a dressing folder; at least two transferably detachable self-adhesive mnemonic markers; and, a skin marking device having means for its removable attachment to the program, wherein the inner face of the program has means for the removable receipt of the site preparation card and for the removable receipt of the transparent dressings held in the dressing folder, and means for the removable receipt of the transferably detachable self-adhesive mnemonic markers. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0015]      FIG. 1  is a schematic illustration of a hemodialysis access configuration in the form of an arterio-venous fistula.  
         [0016]      FIG. 2  is a schematic illustration of a hemodialysis access configuration in the form of an straight arterio-venous graft.  
         [0017]      FIG. 3  is a schematic illustration of a hemodialysis access configuration in the form of an looped arterio-venous graft.  
         [0018]      FIG. 4  is a schematic perspective illustration of the invention.  
         [0019]      FIG. 5  is a schematic illustration of a skin marking device.  
         [0020]      FIG. 6  is a schematic illustration of an exemplary transparent dressing.  
         [0021]      FIG. 7  is a schematic illustration of an exemplary dressing folder.  
         [0022]      FIG. 8   a  is schematic perspective illustration of an inner face of a program of the invention.  
         [0023]      FIG. 8   b  is schematic perspective illustration of an outer face of a program of the invention.  
         [0024]      FIG. 9  is a plan view of an inner face of an exemplary SAVG program of the invention.  
         [0025]      FIG. 10   a  is a partial plan view of a third exemplary outer program panel of an outer face of an exemplary SAVG program of the invention.  
         [0026]      FIG. 10   b  is a partial plan view of a first exemplary outer program panel of an outer face of an exemplary SAVG program of the invention.  
         [0027]      FIG. 11  is a plan view of an inner face of an exemplary AVF program of the invention.  
         [0028]      FIG. 12   a  is a partial plan view of a third exemplary outer program panel of an outer face of an exemplary AVF program of the invention.  
         [0029]      FIG. 12   b  is a partial plan view of a first exemplary outer program panel of an outer face of an exemplary AVF program of the invention.  
         [0030]      FIG. 13  is a plan view of an inner face of an exemplary LAVG program of the invention.  
         [0031]      FIG. 14   a  is a partial plan view of a third exemplary outer program panel of an outer face of an exemplary LAVG program of the invention.  
         [0032]      FIG. 14   b  is a partial plan view of a first exemplary outer program panel of an outer face of an exemplary LAVG program of the invention.  
         [0033]      FIG. 15   a  is a plan view of the front of an exemplary site preparation card.  
         [0034]      FIG. 15   b  is a plan view of the back of an exemplary site preparation card.  
         [0035]      FIG. 16  is a schematic illustration of a linear array of mnemonic markers.  
         [0036]      FIG. 17  is a schematic illustration of a parallel array of mnemonic markers.  
         [0037]      FIG. 18  is a schematic illustration of an image field of exemplary site preparation card containing an exemplary reproduction of an AVF hemodialysis access configuration.  
         [0038]      FIG. 19  is a schematic illustration of an image field of exemplary site preparation card containing an exemplary reproduction of an SAVG hemodialysis access configuration.  
         [0039]      FIG. 19   a  is a schematic illustration of the appearance of a reproduction of an AVF hemodialysis configuration just prior to a first hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a first hemodialysis session.  
         [0040]      FIG. 19   b  is a schematic illustration of the appearance of a reproduction of an AVF hemodialysis configuration just prior to a second hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a second hemodialysis session.  
         [0041]      FIG. 19   d  is a schematic illustration of the appearance of a reproduction of an AVF hemodialysis configuration just prior to a third hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a third hemodialysis session.  
         [0042]      FIG. 19   d  is a schematic illustration of the appearance of a reproduction of an AVF hemodialysis configuration just prior to a fourth hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a fourth hemodialysis session.  
         [0043]      FIG. 19   e  is a schematic illustration of the appearance of a reproduction of an AVF hemodialysis configuration just prior to a fifth hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a fifth hemodialysis session.  
         [0044]      FIG. 20  is a schematic illustration of an image field of exemplary site preparation card containing an exemplary reproduction of an LAVG hemodialysis access configuration.  
         [0045]      FIG. 20   a  is a schematic illustration of the appearance of a reproduction of an AVF hemodialysis configuration just prior to a first hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a first hemodialysis session.  
         [0046]      FIG. 20   b  is a schematic illustration of the appearance of a reproduction of an LAVG hemodialysis configuration just prior to a second hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a second hemodialysis session.  
         [0047]      FIG. 20   c  is a schematic illustration of the appearance of a reproduction of an LAVG hemodialysis configuration just prior to a third hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a third hemodialysis session.  
         [0048]      FIG. 20   d  is a schematic illustration of the appearance of a reproduction of an LAVG hemodialysis configuration just prior to a fourth hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a fourth hemodialysis session.  
         [0049]      FIG. 20   e  is a schematic illustration of the appearance of a reproduction of an LAVG hemodialysis configuration just prior to a fifth hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a fifth hemodialysis session.  
         [0050]      FIG. 20   f  is a schematic illustration of the appearance of a reproduction of an LAVG hemodialysis configuration just prior to a sixth hemodialysis session and also shows the appearance of vertically arrayed placeholders just prior to a sixth hemodialysis session.  
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0051]     As indicated hereinabove, a patient with ESRD must have a hemodialysis access configuration surgically constructed, along which, at hemodialysis cannulation sites, paired arterial and venous needles are inserted for withdrawing toxin-laden blood and returning freshly-dialyzed blood. Hemodialysis access configurations commonly take the form of an AVF, SAVG or LAVG, which are respectively shown in  FIG. 1 ,  FIG. 2  and  FIG. 3   
         [0052]     In  FIG. 1 , a hemodialysis access configuration in the form of an AVF  111  is shown in a semi-transparent supinated forearm  110  of a hemodialysis patient. AVF  111  surgically unites forearm vein  114  and forearm artery  115 . Efferent hemodialysis cannulation site  116  and afferent hemodialysis cannulation site  117  respectively provide access for efferent flow tubing  118  to a hemodialyzer (not shown) and afferent flow tubing  119  from a hemodialyzer.  
         [0053]     In  FIG. 2 , a hemodialysis access configuration in the form of a SAVG  112  is shown in a semi-transparent supinated forearm  110  of a hemodialysis patient. SAVG  112  forms a straight conduit that unites forearm vein  114  and forearm artery  115 .  
         [0054]     In  FIG. 3 , a hemodialysis access configuration in the form of a LAVG  113  is shown in a semi-transparent supinated forearm  110  of a hemodialysis patient. LAVG  113  forms a looped conduit that unites forearm vein  114  and forearm artery  115 .  
         [0055]     There is shown in  FIG. 4 a  perspective schematic illustration of a common exemplary embodiment of a device  1  for the rotatable selection, preparation and recollection of hemodialysis cannulation sites along a hemodialysis access configuration of a patient with ESRD, comprising a foldable sheet of material (hereinafter “program”)  10  having an inner face  10   a , and an outer face  10   b , an exemplary site preparation card  20 , two exemplary transparent dressings  2   a  and  2   b  encased in an exemplary dressing folder  90 , a plurality of exemplary numbered self-adhesive mnemonic markers (“mnemonic markers”)  3 , and an exemplary skin marking device  100 .  
         [0056]     As shown in  FIG. 4 , inner face  10   a  of program  10  has means  11  for the removable receipt of exemplary site preparation card  20  and the removable receipt of exemplary transparent dressings  2   a  and  2   b  encased in an exemplary dressing folder  90 . Inner face  10   a  of program  10  also has means  13  for the removable receipt of exemplary mnemonic markers  3 .  
         [0057]     Exemplary skin marking device  100  has means  14  for the removable attachment of exemplary skin marking device  100  to program  10 .  
         [0058]     Exemplary skin marking device  100  for use in conjunction with program  10  is shown in greater detail in  FIG. 5 . Exemplary skin marking device  100  is carried upon or within program  10  by means  14  for the removable attachment of skin marking device  100  to program  10 . Exemplary skin marking device  100  is used by an ESRD patient to mark portions of skin overlying a hemodialysis access configuration that have been selected as hemodialysis cannulation sites by the ESRD patient using the invention. About 1 to 2 hours before an anticipated hemodialysis session and following the selection of hemodialysis cannulation sites by methods described hereinbelow, the ESRD patient&#39;s actual hemodialysis cannulation sites, corresponding to representative hemodialysis sites selected from an image of the ESRD patient&#39;s hemodialysis access configuration appearing on exemplary site preparation card  20 , are marked with exemplary marking device  100 .  
         [0059]     Exemplary skin marking device  100  for use in conjunction with program  10  is sized to be comfortably used as an instrument for making marks by hand, even by those ESRD patients having limited mobility owing to an infirmity of the hands. Exemplary skin marking device  100  effectively functions as a stamp that outlines a circular area of the skin of an ESRD patient merely by pressing skin marking device  100  against the skin.  
         [0060]     Exemplary marking device  100  for use in conjunction with program  10  is comprised of a tubular body  101  that is adapted to be fitted by a cap  102 . Tubular body  101  is comprised of an outer cylinder  103  concentric about an inner cylinder  104 , between which cylinders there is circumferentially disposed an exemplary set of eight markers  105  that are equidistant from one another. Exemplary set of eight markers  105  are secured in annular space  106  between outer cylinder  103  and inner cylinder  104  by nontoxic glue, or any other substantially equivalent adhesive substance. Outer cylinder  103  may be made of metal or plastic, or a substantially equivalent material, and has a radius of about 12/16 inch, a length of about 6 inches and a thickness of about 1/16 inch. Inner cylinder  104  may also be made of metal or plastic, or a substantially equivalent material, and has a radius of about 10/16 inch, a length of about 6 inches and a thickness of about 1/16 inch.  
         [0061]     Exemplary set of eight markers  105  may, for example, be comprised of felt-tipped markers, or any other substantially equivalent device or instrument suitable for the carriage of non-permanent, non-toxic ink for marking the skin. Marking tips  107  of exemplary set of eight markers  105  extend beyond top margin  108  of tubular body  101  and, when pressed against the skin of an ESRD patient cause an exemplary eight dots to be marked that define a circle outlining an actual hemodialysis cannulation site selected by the ESRD patient.  
         [0062]     There is affixed to outer cylinder  103 , means  14  for the removable attachment of exemplary skin marking device  100  to program  10 . Means  14  may, for example, comprise a clip, as shown in  FIG. 5 , or a clasp, clamp or substantially equivalent fastening device or, for example, a strip of material, such as, for example, Velcro®, affixed onto exemplary skin marking device  100  so that exemplary skin marking device  100  may be removably attached to program  10 .  
         [0063]     Two exemplary transparent dressings  2   a  and  2   b  for use in conjunction with program  10  are shown in  FIG. 6 . Exemplary transparent dressings  2   a  and  2   b  are held in exemplary dressing folder  90 , shown in greater detail in  FIG. 7 , for use in conjunction with program  10 . Exemplary dressing folder  90  is also more fully described hereinbelow.  
         [0064]     Exemplary transparent dressings  2   a  and  2   b  are used by an ESRD patient as a protective coverings over portions of skin that have been selected as actual hemodialysis cannulation sites using the invention. Following the selection of these actual hemodialysis cannulation sites by an ESRD patient using the methods described hereinbelow, and about 1 to 2 hours before an anticipated hemodialysis session, the selected actual hemodialysis cannulation sites, having been marked with exemplary skin marking device  100  ( FIG. 4  and  FIG. 5 ), are coated with a dollop of anesthetic ointment, such as, for example, EMLA® cream or an ointment containing lidocaine, prilocaine, or a substantially equivalent anesthetic ingredient. After applying the anesthetic ointment, exemplary transparent dressings  2   a  and  2   b  are placed over the skin to prevent smearing and dilution of the anesthetic ointment, and to maintain the anesthetic ointment in contact with the skin of the selected actual hemodialysis cannulation sites.  
         [0065]     In  FIG. 6 , Exemplary transparent dressings  2   a  and  2   b  for use in conjunction with program  10  are seen to comprise respective adhesive border portions  2   c  and  2   d  contiguously framing respective nonadhesive transparent central windows  2   e  and  2   f , both of which are removably attached to a common backing  2   g  by an adhesive surface of adhesive border portions  2   c  and  2   d.    
         [0066]     Adhesive border portions  2   c  and  2   d  may, for example, be made of paper or plastic surgical tape, or a substantially equivalent material having a side adhesive to the skin. Adhesive border portions  2   c  and  2   d  may have a width of about 1/2 inch. Each adhesive border portion  2   c  and  2   d  is respectively folded over upon itself to form an exemplary octagonal border about each nonadhesive transparent central window  2   e  and  2   f . Transparent central windows  2   e  and  2   f  may, for example, be made of cellophane, saran polyvinylidene chloride (PVDC), Mylar®, or a substantially equivalent nonadhesive transparent material, forming a square (dashed lines in  FIG. 6 ) about 1.25 inches on each side, which square is secured to the respective adhesive sides of border portions  2   c  and  2   d  which form the octagonal border about respective transparent central portions  2   e  and  2   f.    
         [0067]     Common backing  2   g  be made of paper or plastic, or a substantially equivalent material, in the approximate form of a rectangle having one side about 2 inches long and another side about 4 inches long, to which exemplary transparent dressing  2   a  and  2   b  are respectively detachably adhesive. The transparency of each central portion  2   e  and  2   f  of respective exemplary transparent dressings  2   a  and  2   b  enables an ESRD patient to visualize a dollop of anesthetic ointment as it is being covered with the dressing.  
         [0068]     Exemplary dressing folder  90  for use in conjunction with program  10  contains two exemplary transparent dressings  2   a  and  2   b  and is shown in  FIG. 7 . Exemplary dressing folder  90  for use in conjunction with program  10  may, for example, be made of a sheet of paper, plastic, metal foil or a substantially equivalent material. Exemplary dressing folder  90  for use in conjunction with program  10  measures about 6.5 inches in width and about 5 inches in height when it is unfolded. Exemplary dressing folder  90  is carried upon or within program  10  by means  11  for the removable receipt of exemplary dressing folder  90 .  
         [0069]     Means  11  may comprise a pocket or sleeve or other means for removably receiving exemplary dressing folder  90  upon or within program  10 . In  FIG. 4 , means  11  is shown as an exemplary pocket that holds both exemplary dressing folder  90  and exemplary site preparation card  20  upon or within program  10 .  
         [0070]     As shown in  FIG. 7 , the sheet of material used to fashion exemplary dressing folder  90  may be twice folded vertically along a first vertical fold line  91  and a second vertical fold line  92  so as to define a first vertical portion  93 , a second vertical portion  94  and a third vertical portion  95  of exemplary dressing folder  90 , each vertical portion being hingedly articulated vertically along first vertical fold line  91  and a second vertical fold line  92 .  
         [0071]     As shown in  FIG. 7 , the sheet of material used to fashion exemplary dressing folder  90  may also be folded once horizontally along a horizontal fold line  96 , to define an inferior horizontal portion  97 , having a first segment  97   a , that corresponds to first vertical portion  93 , a second segment  97   b , that corresponds to second vertical portion  94 , and a third segment  97   c , that corresponds to third vertical portion  95 . In fashioning exemplary dressing folder  90 , first segment  97   a  and third segment  97   c  of inferior horizontal portion  97  are excised (indicated by hatching in  FIG. 7 ), leaving only second segment  97   b . Second segment  97   b  of inferior horizontal portion  97  is hingedly articulated horizontally along horizontal fold line  96 .  
         [0072]     Vertical portions  93 ,  94  and  95  have corresponding inner faces  93   a ,  94   a  and  95   a , and corresponding outer faces  93   b ,  94   b  and  95   b , upon which textual, graphic, symbolic or iconic information may be printed.  
         [0073]     In  FIG. 7 , two exemplary transparent dressings  2   a  and  2   b  are shown. Exemplary transparent dressings  2   a  and  2   b  are held against second vertical portion  94  of exemplary dressing folder  90  by first folding second segment  97   b  of inferior horizontal portion  97 , then folding third vertical portion  95  over second vertical portion  94 , and finally folding first vertical portion  93  over third vertical portion  95  that has been folded over second vertical portion  94 .  
         [0074]     Exemplary mnemonic markers  3  ( FIG. 4 ) for use in conjunction with program  10  are shown in greater detail in  FIG. 16  and  FIG. 17 , and are more fully described hereinbelow.  
         [0075]     Exemplary mnemonic markers  3  are carried upon or within program  10  by means  13  ( FIG. 4 ) for the removable receipt of exemplary mnemonic markers  3 . Means  13  for the removable receipt exemplary mnemonic markers  3  may comprise a coating, laminate or patch of transparent material upon program  10  to which coating, laminate or patch exemplary mnemonic markers  3  are removably self adhesive.  
         [0076]     Exemplary site preparation card  20  ( FIG. 4 ) for use in conjunction with program  10  is discussed in greater detail hereinbelow Three exemplary embodiments of exemplary site preparation card  20 , corresponding to three exemplary embodiments of the invention, are respectively shown in  FIG. 18 ,  FIG. 19  and  FIG. 20 .  
         [0077]     Exemplary site preparation card  20  is carried upon or within program  10  by means  11  ( FIG. 4 ) for the removable receipt of exemplary site preparation card  20 . Means  11  may, for example, comprise a sleeve, fold, adhesive strip, slots, or other means for removably receiving exemplary site preparation card  20  upon or within program  10 . In  FIG. 4 , means  11  for the removable receipt of exemplary site preparation card  20  is shown as an exemplary pocket  11   a , that is fashioned out of the material of program  10 . Exemplary pocket  1   a  is closed on its lateral sides  11   b ,  11   c , and inferior side  11   d , thereby forming an insert space into which exemplary site preparation card  20  and exemplary dressing folder  90  are placed.  
         [0078]     Program  10  ( FIG. 4 ) may, for example, be made of paper, plastic, metal foil or a substantially equivalent material. Program  10  is carried on the person of an ESRD patient, and may, for example, measure about 8 inches in height, and about 10 inches in width when fully unfolded  
         [0079]      FIG. 8   a  shows program  10  ( FIG. 4 ) and inner face  10   a  ( FIG. 4 ) of program  10  in greater detail. In  FIG. 8   a , program  10  can be seen to be comprised of a set of exemplary program panels  15   a ,  15   b  and  15   c , respectively denominated as instructional panel  15   a , insert panel  15   b  and placeholder panel  15   c . Instructional panel  15   a , insert panel  15   b  and placeholder panel  15   c  are respectively divided from one another, and may be hingedly articulated from one another, by lines  5   ab  and  5   bc . Lines  5   ab  and  5   bc  may, for example, be formed by folds or creases in program  10 , or by hinging means, such as, for example, rings or a spiral coil, fashioned into program  10 ; or, lines  5   ab  and  5   bc  may be printed upon inner face  10   a  of program  10 . As shown in  FIG. 8   a , each exemplary inner program panel  15   a ,  15   b  and  15   c  respectively contains an exemplary inner program field  16   a ,  16   b  and  16   c , that collectively comprise a set of inner program fields.  
         [0080]      FIG. 8   b  shows outer face  10   b  ( FIG. 4 ) of a program  10  ( FIG. 4 ) in greater detail. As shown in  FIG. 8   b , outer face  10   b  of program  10  is comprised of a set of exemplary outer program panels,  17   a ,  17   b  and  17   c . As shown in  FIG. 8   b , each exemplary outer program panel  17   a ,  17   b  and  17   c  respectively contains an exemplary outer program field,  18   a ,  18   b  and  18   c , comprising a set of outer program fields. In  FIG. 8   b , exemplary outer program panels,  17   a ,  17   b , and  17   c  of outer face  10   b  of program  10  are respectively divided from one another by lines  5   ab  and  5   bc . Exemplary inner program panels  15   a ,  15   b , and  15   c  shown in  FIG. 8   a  respectively correspond to exemplary outer program panels,  17   a ,  17   b , and  17   c , shown in  FIG. 8   b.    
         [0081]     In  FIG. 8   a , each exemplary inner program field, such as exemplary inner program field  16   b , defines a space within an inner program panel, such as insert panel  15   b , for the placement of textual, graphic, symbolic or iconic information, or defines a space within an inner program panel, such as insert panel  15   b , for the location of the aforementioned means  11  ( FIG. 4 ) for removably receiving exemplary site preparation card  20  and for removably receiving exemplary transparent dressings  2   a  and  2   b  encased in exemplary dressing folder  90 , or for the location of the aforementioned means  13  ( FIG. 4 ) for removably receiving exemplary mnemonic markers  3 .  
         [0082]     Each exemplary outer program field, such as exemplary outer program field  18   b  ( FIG. 8   b ), defines a space within an outer program panel, such as outer program panel  17   b  ( FIG. 8   b ), for the placement of textual, graphic, symbolic or iconic information.  
         [0083]     Three exemplary embodiments of the invention described hereinafter share the common exemplary embodiment of device  1  described hereinabove, shown as an integrated ensemble in  FIG. 4 , and shown in component detail in  FIG. 5 ,  FIG. 6 ,  FIG. 7 ,  FIG. 8   a  and  FIG. 8   b . However, each exemplary embodiment of the invention described hereinafter is distinguished by the location, arrangement, content, and use of the program fields contained in the program panels of their respective programs  10 , and the content of their corresponding exemplary site preparation cards  20 .  
         [0084]     There is shown in  FIG. 9 a  plan view of inner face  10   a  of an exemplary SAVG embodiment of program  10  of the invention. In  FIG. 9 , instructional panel  15   a  contains one inner program field  16   a  with exemplary text for instructing an ESRD patient whose hemodialysis access configuration comprises a SAVG on the use of the invention.  
         [0085]     In  FIG. 9 , insert panel  15   b  contains one inner program field  16   b  that provides the aforementioned means  11  for removably receiving exemplary site preparation card  20  ( FIG. 4  and  FIGS. 18-20  infra.) and for removably receiving exemplary transparent dressings  2   a  and  2   b  ( FIG. 6 ) encased in exemplary dressing folder  90  ( FIG. 7 ).  
         [0086]     In  FIG. 9 , placeholder panel  15   c  contains one inner program field  16   c  holding text instructing an ESRD patient whose hemodialysis access configuration comprises a SAVG on the use of exemplary mnemonic markers  3 , another inner program field  16   cc  (hereinafter “marker placement field”) providing the aforementioned means  13  ( FIG. 4 ) for the removably receiving exemplary mnemonic markers  3  (not shown in  FIG. 9 ), and yet another inner program field  16   ccc  holding an exemplary manufacturer&#39;s logo. In  FIG. 9 , marker placement field  16   cc  is shown with two vertically arrayed circular placeholders  26  for the removable receipt of two exemplary mnemonic markers  3  (not shown in  FIG. 9 ).  
         [0087]     There is shown in  FIG. 10   a  and  10   b  partial plan views of outer face  10   b  of an exemplary SAVG embodiment of program  10  of the invention.  FIG. 10   a  shows a plan view of third exemplary outer program panel  17   c  of outer face  10   b  of program  10 , wherein third exemplary outer program panel  17   c  is seen to contain third exemplary outer program field  18   c , holding both exemplary graphic information and exemplary text identifying program  10  as a program for the SAVG embodiment of the invention.  FIG. 10   b  shows a plan view of first exemplary outer program panel  17   a  of outer face  10   b  of program  10 , wherein first exemplary outer program panel  17   a  is seen to contain first exemplary outer program field  18   a , holding an exemplary manufacturer&#39;s logo and contact information.  
         [0088]     There is shown in  FIG. 11 a  plan view of inner face  10   a  of an exemplary AVF embodiment of program  10  of the invention. In  FIG. 11 , instructional panel  15   a  contains one inner program field  16   a  with exemplary text for instructing an ESRD patient whose hemodialysis access configuration comprises an AVF on the use of the invention.  
         [0089]     In  FIG. 11 , insert panel  15   b  contains one inner program field  16   b  that provides the aforementioned means  11  for removably receiving exemplary site preparation card  20  ( FIG. 4  and  FIGS. 18-20  infra.) and for removably receiving exemplary transparent dressings  2   a  and  2   b  ( FIG. 6 ) encased in exemplary dressing folder  90  ( FIG. 7 ).  
         [0090]     In  FIG. 11 , placeholder panel  15   c  contains one inner program field  16   c  holding text instructing a patient with ESRD whose hemodialysis access configuration comprises an AVF on the use of exemplary mnemonic markers  3 , another inner program field  16   cc  (“marker placement field”) providing the aforementioned means  13  ( FIG. 4 ) for the removable receipt of exemplary mnemonic markers  3  (not shown in  FIG. 11 ), and yet another inner program field  16   ccc  holding an exemplary manufacturer&#39;s logo. In  FIG. 11 , marker placement field  16   cc  is shown with two vertically arrayed circular placeholders  26  for the removable receipt of two exemplary mnemonic markers  3  (not shown in  FIG. 11 ).  
         [0091]     There is shown in  FIGS. 12   a  and  12   b  partial plan views of outer face  10   b  ( FIG. 4 ) of an exemplary AVF embodiment of program  10  of the invention.  FIG. 12   a  shows a plan view of third exemplary outer program panel  17   c  of outer face  10   b  of program  10 , wherein third exemplary outer program panel  17   c  is seen to contain third exemplary outer program field  18   c  holding both exemplary graphic information and exemplary text describing program  10  as a program for the AVF embodiment of the invention.  FIG. 12   b  shows a plan view of first exemplary outer program panel  17   a  of outer face  10   b  of program  10 , wherein first exemplary outer program panel  17   a  is seen to contain first exemplary outer program field  18   a  holding an exemplary manufacturer&#39;s logo and contact information.  
         [0092]     There is shown in  FIG. 13 a  plan view of inner face  10   a  an exemplary LAVG embodiment of program  10  of the invention. In  FIG. 13 , instructional panel  15   a  contains one inner program field  16   a  with exemplary text for instructing an ESRD patient whose hemodialysis access configuration comprises a LAVG on the use of the invention.  
         [0093]     In  FIG. 13 , insert panel  15   b  contains one inner program field  16   b  that provides the aforementioned means  11  for removably receiving exemplary site preparation card  20  ( FIG. 4  and  FIGS. 18-20  infra.) and for removably receiving exemplary transparent dressings  2   a  and  2   b  ( FIG. 6 ) encased in exemplary dressing folder  90  ( FIG. 7 ).  
         [0094]     In  FIG. 13 , placeholder panel  15   c  contains one inner program field  16   c  holding text instructing a patient with ESRD whose hemodialysis access configuration comprises a LAVG on the use of exemplary mnemonic markers  3 , another inner program field  16   cc  (“marker placement field”) providing the aforementioned means  13  for the removable receipt of exemplary mnemonic markers  3  (not shown in  FIG. 13 ), and yet another inner program field  16   ccc  holding an exemplary manufacturer&#39;s logo. In  FIG. 13  marker placement field  16   cc  is shown with two vertically arrayed circular placeholders  27  for the removable receipt of two exemplary mnemonic markers  3  (not shown in  FIG. 13 ).  
         [0095]     There is shown in  FIGS. 14   a  and  14   b  partial plan views of outer face  10   b  an exemplary LAVG embodiment of program  10  of the invention.  FIG. 14   a  shows a plan view of third exemplary outer program panel  17   c  of outer face  10   b  of program  10 , wherein third exemplary outer program panel  17   c  is seen to contain third exemplary outer program field  18   c  holding both exemplary graphic information and exemplary text describing program  10  as the program for the LAVG embodiment of the invention.  FIG. 14   b  shows a plan view of first exemplary outer program panel  17   a  of outer face  10   b  of program  10 , wherein first exemplary outer program panel  17   a  is seen to contain first exemplary outer program field  18   a  holding an exemplary manufacturer&#39;s logo and contact information.  
         [0096]     Exemplary site preparation card  20  is shown in greater detail in  FIG. 15   a  and  FIG. 15   b . In  FIG. 15   a , exemplary site preparation card  20  is seen to comprise a sheet of card material  21  having a front face  21   a .  FIG. 15   b  shows a back face  21   b  of site preparation card  20 . As indicated hereinabove, exemplary site preparation card  20  is removably receivable on or within insert panel  15   b  ( FIG. 8   a ) of program  10  by the aforementioned means  11  ( FIGS. 9, 11  and  13 ).  
         [0097]     Exemplary site preparation card  20  may, for example, also be made of paper, plastic, metal foil or a substantially equivalent material. Exemplary site preparation card  20  may, for example, measure about 8 inches in height and about 3 inches in width.  
         [0098]     In  FIG. 15   a , front face  21   a  of sheet of card material  21  is laminated with a transparent coating, indicated in  FIG. 15   a  by the area enclosed by dashed lines  22 , upon which transparent coating  22  self-adhesive exemplary mnemonic markers  3  ( FIGS. 9, 11  and  13 ) may be detachably and reversibly transferred to and from placeholder inner program panel  15   c  ( FIGS. 9, 11  and  13 ) of program  10 .  
         [0099]     In  FIG. 15   a , front face  21   a  of sheet of card material  21  contains a set of site preparation fields among which there is included a title site preparation field  23   a  (“title field”) and an image site preparation field  23   d  (“image field”). Title field  23   a  may, for example, contain text identifying exemplary site preparation card  20  as intended for use by a patient with ESRD having an AVF hemodialysis access configuration, a SAVG hemodialysis access configuration or a LAVG hemodialysis access configuration. Image field  23   d  contains a reproduction of the hemodialysis access configuration of an ESRD patient using the invention, such as, for example, an AVF, a SAVG or a LAVG.  
         [0100]     In  FIG. 15   b , back face  21   b  of sheet of card material  21  contains a set of site preparation fields among which there is included a patient data site preparation field  23   b  (“patient field”) and an instruction site preparation field  23   c . Patient data field  23   b  may, for example, contain text identifying the name of the ESRD patient, the name and telephone number of the ESRD patient&#39;s health care provider, the address and telephone number of the patient&#39;s hemodialysis center, and substantially similar identifying information having medical relevance. Instruction site preparation field  23   c  may, for example, contain information instructing an ESRD patient on the location, preparation and recollection of a hemodialysis cannulation sites along a hemodialysis access configuration.  
         [0101]     The reproduction of the hemodialysis access configuration may be obtained by reproductive means, such as, for example, conventional photography, digital photography, manual drawing, digital imaging or substantially equivalent means. The reproduction of the hemodialysis access configuration may be transferred to image field  23   d  by transfer means such as, for example, printing, lithography, photocopying, or substantially equivalent means.  
         [0102]      FIG. 16  shows an exemplary vertical column  8  (hereinafter “exemplary linear array”) of ten mnemonic markers  3 , comprising two sets of five mnemonic markers, bearing numbers 1, 2, 3, 4, 5 on their anterior surfaces. Exemplary linear array of mnemonic markers is used in the rotatable selection, preparation and recollection of hemodialysis cannulation sites along an AVF or SAVG hemodialysis access configuration of an ESRD patient.  
         [0103]      FIG. 17  shows two exemplary vertical columns  9  ((hereinafter “exemplary parallel array”) of six exemplary mnemonic markers  3 , comprising two sets of six mnemonic markers, each bearing numbers 1, 2, 3, 4, 5, 6 on their anterior surfaces. Exemplary parallel array of mnemonic markers is used in the rotatable selection, preparation and recollection of hemodialysis cannulation sites along a LAVG hemodialysis access configuration of an ESRD patient.  
         [0104]     An exemplary mnemonic marker  3  may be of any shape, but is conveniently illustrated in  FIG. 16  and  FIG. 17  as a circle having a diameter of about 1/2 inch. An exemplary mnemonic marker may be of any color, and may be made of paper, plastic, metallic foil or a substantially equivalent material. The posterior surface of each exemplary mnemonic marker has a quality of “stickiness,” i.e., it is endowed with an impermanent adhesiveness that makes it removably and transferably adhesive to both the surface of image field  23   d  ( FIG. 15   a ) and marker placement field  16   cc  contained in placement panel  15   c  of program  10  ( FIGS. 9, 11  and  13 ). This impermanent adhesiveness may, for example, be secured by an appropriate sticky coating or by static cling that obtains between the posterior surface of an exemplary mnemonic marker  3  and the surfaces of both image field  23   d  ( FIG. 15   a ) and marker placement field  16   cc  contained in placement panel  15   c  of program  10  ( FIGS. 9, 11  and  13 ).  
         [0105]      FIG. 18  shows image field  23   d  of exemplary site preparation card  20  alongside placeholder panel  15   c  of program  10 . In  FIG. 18 , image field  23   d  contains an exemplary reproduction of an AVF hemodialysis access configuration. Placeholder panel  15   c  contains inner program field  16   c  holding text instructing a patient with ESRD whose hemodialysis access configuration comprises an AVF on the use of exemplary mnemonic markers  3 . Marker placement field  16   cc  providing means  13  ( FIG. 4 ) for the removable receipt of exemplary mnemonic markers  3  (not shown in  FIG. 18 ). Inner program field  16   ccc  holds an exemplary manufacturer&#39;s logo. Marker placement field  16   cc  is shown with two vertically arrayed circular placeholders  26  for the removable receipt of two exemplary mnemonic markers  3  (not shown in  FIG. 18 ). When image field  23   d  contains an exemplary reproduction of an AVF (or a SAVG) hemodialysis access configuration, it is used in conjunction with exemplary linear array of mnemonic markers  8  shown in  FIG. 16 .  
         [0106]     When, as shown in  FIG. 18 , image field  23   d  contains an exemplary reproduction of an AVF hemodialysis access configuration, a set of image identification fields (identified in  FIG. 18  by reference numerals  25   e  through  25   m ) is superimposed upon the AVF hemodialysis access configuration. As shown in  FIG. 18 , the set of image identification fields  25  includes: elbow image identification field  25   e  that may, for example, may the word “Elbow;” wrist image identification field  25   f  that may, for example, contain the word “Wrist;” and, Arterial End image identification field  25   i  that may, for example, contain the words “end of artery,” or the words “Arterial end.” Arterial End image identification field  25   i  is proximal to wrist image identification field  25   f  and is associated with Arterial Start image identification field  25   l , that may, for example, contain the words “Artery start,” or the words “Arterial start.” 
         [0107]     The set of image identification fields further includes Venous End image identification field  25   k  that may, for example contain the words “Venous end” or “End of vein.” Venous End image identification field  25   k  is proximal to elbow image identification field  25   e , and is also associated with Venous Finish image identification field  25   m , that may, for example, contain the words “Vein finish,” or the words “Venous finish.” 
         [0108]     The set of image identification fields additionally includes Midpoint image identification field  25   j  that may, for example contain the word “Midpoint” or the word “Middle.” Midpoint image identification field  25   j  identifies the approximate anatomic midpoint of an AVF hemodialysis access configuration. Midpoint image identification field  25   j  is associated with a slightly distal (wrist-ward)  
         [0109]     Arterial Finish image identification field  25   h  that may, for example contain the word “Finish” or the words “Arterial finish.” Midpoint image identification field  25   j  is also associated with a slightly proximal (elbow-ward) Venous Start image identification field  25   g  that may, for example contain the word “start” or the words “Venous start.” 
         [0110]     As shown in  FIG. 18 , between Arterial Finish image identification field  25   l  and Arterial Finish position image identification field  25   h , there is superimposed a first approximately linear array of an exemplary five AVF circles  30 ; and, between Venous Start image identification field  25   g  and Venous Finish image identification field  25   m , there is superimposed a second approximately linear array of an exemplary five AVF circles  40 .  
         [0111]     The circles of first approximately linear array of an exemplary five AVF circles  30  are numbered in ascending order from 1 to 5, the first such circle being about coincident with Arterial Start image identification field  25   l , and the 5th such circle being about coincident with Arterial Finish image identification field  25   h . First approximately linear array of an exemplary five AVF circles  30  overlies the expanse of an AVF from Arterial Start image identification field  25   l  to Arterial Finish image identification field  25   h.    
         [0112]     The circles of second approximately linear array of an exemplary five AVF circles  40  are also numbered in ascending order from 1 to 5, the first such circle being about coincident with Venous Start image identification field  25   g , and the 5th such circle being about coincident with Venous Finish image identification field  25   m . Second approximately linear array of an exemplary five AVF circles  40  overlies the expanse of an AVF from Venous Start image identification field  25   g  to Venous Finish image identification field  25   m.    
         [0113]     Each numbered circle of first approximately linear array of an exemplary five AVF circles  30  comprises an indicator of an actual site at which an arterial access hemodialysis needle is cannulated. Each correspondingly numbered circle of second approximately linear array of an exemplary five AVF circles  40  comprises an indicator of a corresponding actual site at which a venous access hemodialysis needle is simultaneously cannulated.  
         [0114]     Accordingly, the circles of first approximately linear array of an exemplary five AVF circles  30  and second approximately linear array of an exemplary five AVF circles  40  identify successively paired representative arterial and venous cannulation sites along the AVF hemodialysis configuraton and serve as placeholders for correspondingly numbered mnemonic markers of exemplary linear array  8  shown in  FIG. 16 .  
         [0115]     Correspondingly numbered circles of first approximately linear array of an exemplary five AVF circles  30  and second approximately linear array of an exemplary five AVF circles  40  comprise representative arterio-venous cannulation site pairs that are successively employed in an exemplary five successive hemodialysis sessions that comprise an exemplary hemodialysis cycle.  
         [0116]     By “marching” the paired arterial and venous hemodialysis needles down the numbered pathway of corresponding circles along the AVF, cannulation trauma to the AVF is evenly distributed over time and repeated cannulation of the same sites is avoided. The longevity of the AVF is accordingly extended.  
         [0117]     In the AVF embodiment of the invention: 
    [i] instructional panel  15   a , insert panel  15   b  and placeholder panel  15   c  of program  10 , shown in  FIGS. 9, 11 ,  13 , and inner program fields  16   a ,  16   b  and  16   c  of program  10 , also shown in  FIGS. 9, 11 ,  13 , are adapted to facilitate the rotatable selection, preparation and recollection of actual hemodialysis cannulation sitess along an AVF hemodialysis access configuration of a patient with ESRD;     [ii] instruction site preparation field  23   c  of exemplary site preparation card  20 , shown in  FIG. 15   b , is adapted to instruct an ESRD patient having an AVF hemodialysis access configuration to rotatably select, prepare and recall actual hemodialysis cannulation sites along the AVF hemodialysis access configuration;     [iii] image site preparation field  23   d  of exemplary site preparation card  20 , shown in  FIG. 15   a , is adapted to contain a reproduction of the ESRD patient&#39;s AVF hemodialysis access configuration; and     [iv] image identification fields  25   e  through  25   m  of image site preparation field  23   d  on exemplary site preparation card  20 , shown in  FIG. 18 , are adapted to facilitate the rotatable selection, preparation and recollection of actual hemodialysis cannulation sites along the AVF hemodialysis access configuration of the ESRD patient.    
 
         [0122]      FIG. 19  shows image field  23   d  of exemplary site preparation card  20  alongside placeholder panel  15   c  of program  10 . In  FIG. 19 , image field  23   d  contains an exemplary reproduction of a SAVG hemodialysis access configuration. Placeholder panel  15   c  contains inner program field  16   c  holding text instructing a patient with ESRD whose hemodialysis access configuration comprises a SAVG on the use of exemplary mnemonic markers  3 . Marker placement field  16   cc  provides means  13  ( FIG. 4 ) for the removable receipt of exemplary mnemonic markers  3  (not shown in  FIG. 19 ). Inner program field  16   ccc  holding an exemplary manufacturer&#39;s logo. Marker placement field  16   cc  is shown with two vertically arrayed circular placeholders  26  for the removable receipt of two exemplary mnemonic markers  3  (not shown in  FIG. 19 ). When image field  23   d  contains an exemplary reproduction of a SAVG (or an AVF) hemodialysis access configuration, it is used in conjunction with exemplary linear array of mnemonic markers  8  shown in  FIG. 16 .  
         [0123]     When, as shown in  FIG. 19 , image field  23   d  contains an exemplary reproduction of an SAVG hemodialysis access configuration, a set of image identification fields (identified in  FIG. 19  by reference numerals  25   e  through  25   m ) is superimposed upon the SAVG hemodialysis access configuration. As shown in  FIG. 19 , the set of image identification fields  25  includes: elbow image identification field  25   e  that may, for example, may the word “Elbow;” wrist image identification field  25   f  that may, for example, contain the word “Wrist;” and, Arterial end image identification field  25   i  that may, for example, contain the words “end of artery,” or the words “Arterial end.” Arterial end image identification field  25   i  is proximal to wrist image identification field  25   f  and is associated with Arterial Start image identification field  25   l , that may, for example, contain the words “Artery start,” or the words “Arterial start.” 
         [0124]     The set of image identification fields further includes Venous end image identification field  25   k  that may, for example contain the words “Venous end” or “End of vein.” Venous end image identification field  25   k  is proximal to elbow image identification field  25   e , and is also associated with Venous Finish image identification field  25   m , that may, for example, contain the words “Vein finish,” or the words “Venous finish.” 
         [0125]     The set of image identification fields additionally includes Midpoint image identification field  25   j  that may, for example contain the word “Midpoint” or the word “Middle.” Midpoint image identification field  25   j  identifies the approximate anatomic midpoint of an SAVG hemodialysis access configuration. Midpoint image identification field  25   j  is associated with a slightly distal (wrist-ward) Arterial Finish image identification field  25   h  that may, for example contain the word “Finish” or the words “Arterial finish.” Midpoint image identification field  25   j  is also associated with a slightly proximal (elbow-ward) Venous Start image identification field  25   g  that may, for example contain the word “start” or the words “Venous start.” 
         [0126]     As shown in  FIG. 19 , between Arterial Start image identification field  25   l  and Arterial Finish image identification field  25   h , there is superimposed a first approximately linear array of an exemplary five SAVG circles  50 ; and, between Venous Start image identification field  25   g  and Venous Finish image identification field  25   m , there is superimposed a second approximately linear array of an exemplary five SAVG circles  60 .  
         [0127]     The circles of first approximately linear array of an exemplary five SAVG circles  50  are numbered in ascending order from 1 to 5, the first such circle being about coincident with Arterial Start image identification field  25   l , and the 5th such circle being about coincident with Arterial Finish image identification field  25   h . First approximately linear array of an exemplary five SAVG circles  50  overlies the expanse of an SAVG from Arterial Start image identification field  25   l  to Arterial Finish image identification field  25   h.    
         [0128]     The circles of second approximately linear array of an exemplary five SAVG circles  60  are also numbered in ascending order from 1 to 5, the first such circle being about coincident with Venous Start image identification field  25   g , and the 5th such circle being about coincident with Venous Finish image identification field  25   m . Second approximately linear array of an exemplary five SAVG circles  60  overlies the expanse of an SAVG from Venous Start image identification field  25   g  to Venous Finish image identification field  25   m.    
         [0129]     In the SAVG embodiment of the invention: 
    [i] Instructional panels  15   a , insert panel  15   b  and placeholder panel  15   c  of program  10 , shown in  FIGS. 9, 11 ,  13 , and inner program fields  16   a ,  16   b  and  16   c  of program  10 , also shown in  FIGS. 9, 11 ,  13  are adapted to facilitate the rotatable selection, preparation and recollection of hemodialysis cannulation sitess along a SAVG hemodialysis access configuration of a patient with ESRD;     [ii] instruction site preparation field  23   c  of exemplary site preparation card  20 , shown in  FIG. 15   b , is adapted to instruct an ESRD patient having a SAVG hemodialysis access configuration to rotatably select, prepare and recall hemodialysis cannulation sitess along the SAVG hemodialysis access configuration;     [iii] image site preparation field  23   d  of exemplary site preparation card  20 , shown in  FIG. 15   a , is adapted to contain a reproduction of the ESRD patient&#39;s SAVG hemodialysis access configuration; and     [iv] image identification fields  25   e  through  25   m , as shown in  FIG. 19  and image site preparation field  23   d  on exemplary site preparation card  20 , shown in  FIG. 15   a , are adapted to facilitate the rotatable selection, preparation and recollection of hemodialysis cannulation sitess along the SAVG hemodialysis access configuration of the ESRD patient.    
 
         [0134]     Each numbered circle of first approximately linear array of an exemplary five SAVG circles  50  comprises an indicator of an actual site at which an arterial access hemodialysis needle is cannulated. Each correspondingly numbered circle of second approximately linear array of an exemplary five SAVG circles  60  comprises an indicator of a corresponding actual site at which a venous access hemodialysis needle is simultaneously cannulated.  
         [0135]     Accordingly, the circles of first approximately linear array of an exemplary five SAVG circles  50  and second approximately linear array of an exemplary five SAVG circles  60  identify successively paired representative arterial and venous cannulation sites along the SAVG hemodialysis configuraton and serve as placeholders for correspondingly numbered mnemonic markers of exemplary linear array  8  shown in  FIG. 16 .  
         [0136]     Correspondingly numbered circles of first approximately linear array of an exemplary five SAVG circles  50  and second approximately linear array of an exemplary five SAVG circles  60  comprise representative arterio-venous cannulation site pairs that are successively employed in an exemplary five successive hemodialysis sessions that comprise an exemplary hemodialysis cycle.  
         [0137]     By “marching” the paired arterial and venous hemodialysis needles down the numbered pathway of corresponding circles along the SAVG, cannulation trauma to the SAVG is evenly distributed over time and repeated cannulation of the same sites is avoided. The longevity of the SAVG is accordingly extended.  
         [0138]     Inasmuch as a SAVG hemodialysis access configuration surgically substitutes a tube between an artery and a vein for the surgically created fistula of an AVF hemodialysis access configuration, the exemplary reproduction of an AVF hemodialysis access configuration shown in  FIG. 18 . is equally suitable for the rotatable selection, preparation and recollection of actual hemodialysis cannulation sites along a SAVG hemodialysis access configuration, as shown in  FIG. 19 . Accordingly the discussion that follows in connection with the use of the AVF embodiment of the invention by an ESRD patient with an AVF hemodialysis access configuration is equally applicable to an ESRD patient with a SAVG hemodialysis access configuration.  
         [0139]     When the AVF embodiment of the invention is first given to an ESRD patient having an AVF hemodialysis access configuration, image site preparation field  23   d  on image exemplary site preparation card  20 , already has the exemplary ten mnemonic markers  3  comprising exemplary linear array  8  (shown in  FIG. 19 ) in place within correspondingly numbered circles of first approximately linear array of an exemplary five AVF circles  30 , and second approximately linear array of an exemplary five AVF circles  40 .  
         [0140]      FIG. 19   a  shows the appearance of an exemplary reproduction of an AVF hemodialysis configuration in image site preparation field  23   d  of site preparation card  20  just prior to a first hemodialysis session and also shows the appearance of vertically arrayed placeholders  26  in marker placement field  16   cc  of placeholder panel  15   c  just prior to a first hemodialysis session.  
         [0141]     As shown in  FIG. 19   a , in advance of the first hemodialysis session of an ESRD patient having an AVF hemodialysis configuration, two paired exemplary mnemonic markers numbered 1 are removed from their correspondingly numbered circles overlying the reproduction of the AVF hemodialysis configuration contained in image site preparation field  23   d  on image exemplary site preparation card  20 , and are placed in the two vertically arrayed placeholders  26  contained in marker placement field  16   cc  of placeholder panel  15   c  of program  10 . Arterio-venous cannulation in the forthcoming first hemodialysis session then occurs at actual cannulation sites along the ESRD patient&#39;s actual AVF hemodialysis configuration that correspond to the exposed circles on the reproduction of the ESRD patient&#39;s AVF hemodialysis configuration, from which the paired exemplary mnemonic markers numbered 1 were removed.  
         [0142]      FIG. 19   b  shows the appearance of an exemplary reproduction of an AVF hemodialysis configuration in image site preparation field  23   d  of site preparation card  20  just prior to a second hemodialysis session and also shows the appearance of vertically arrayed placeholders  26  in marker placement field  16   cc  of placeholder panel  15   c  just prior to a second hemodialysis session.  
         [0143]     As shown in  FIG. 19   b , in advance of the next—second—hemodialysis session of an ESRD patient having an AVF hemodialysis configuration, the two paired exemplary mnemonic markers numbered 1 are restored to their original positions in the correspondingly numbered circles overlying the reproduction of the AVF hemodialysis configuration contained in image site preparation field  23   d  on image exemplary site preparation card  20 , and the two paired exemplary mnemonic markers numbered 2 are removed from their correspondingly numbered circles and are placed in the two vertically arrayed placeholders  26  contained in marker placement field  16   cc  of placeholder panel  15   c  of program  10 . Arterio-venous cannulation in the forthcoming second hemodialysis session then occurs at actual cannulation sites along the ESRD patient&#39;s actual AVF hemodialysis configuration that correspond to the exposed circles on the reproduction of the ESRD patient&#39;s AVF hemodialysis configuration, from which the paired exemplary mnemonic markers number 2 were removed.  
         [0144]      FIGS. 19   c  through  19   e  respectively show the appearance of an exemplary reproduction of an AVF hemodialysis configuration in image site preparation field  23   d  just prior to a third, fourth and fifth hemodialysis session and also shows the appearance of vertically arrayed placeholders  26  in marker placement field  16   cc  of placeholder panel  15   c  just prior to a third, fourth and fifth hemodialysis session.  
         [0145]     As shown in  FIGS. 19   c  through  19   e , in advance of the third, fourth and fifth hemodialysis session of an ESRD patient having an AVF hemodialysis configuration, two paired exemplary mnemonic markers respectively numbered 2, 3, 4 are respectively restored to their original positions in correspondingly numbered circles overlying the reproduction of the AVF hemodialysis configuration contained in image site preparation field  23   d  on image exemplary site preparation card  20 , and the two paired exemplary mnemonic markers repectively numbered 3, 4, 5 are removed from their correspondingly numbered circles and are placed in the two vertically arrayed placeholders  26  contained in marker placement field  16   cc  of placeholder panel  15   c  of program  10 . Arterio-venous cannulation in the forthcoming third, fourth and fifth hemodialysis session then occurs at cannulation sites along the ESRD patient&#39;s actual AVF hemodialysis configuration that correspond to the exposed circles on the reproduction of the ESRD patient&#39;s AVF hemodialysis configuration, from which the paired exemplary mnemonic markers numbered 3, 4, 5 were removed.  
         [0146]     Generalizing from the foregoing, an index i={N−(N−x)} may be defined for identifying an ith hemodialysis session in a sequence of N hemodialyis sessions comprising an ESRD patient&#39;s hemodialysis cycle, where x=1, 2, . . . N. When, for example, x=1 and N=5, the first hemodialysis session of the cycle will by identified by i={5−(5−1)}=1. When, for example, x=2 and N=5, the second hemodialysis session of the cycle will by identified by i={5−(5−2)}=2. When, for example, x=N and N=5, the last hemodialysis session of the cycle will by indentified by i={5−(5−5)}=5.  
         [0147]     Following an exemplary ith of N hemodialysis sessions for an ESRD patient having an AVF or SAVG hemodialysis configuration, wherein arterio-venous cannulation occurred at cannulation sites along the ESRD patient&#39;s actual AVF or SAVG hemodialysis configuration corresponding to paired exposed circles numbered i, appearing on the reproduction of the ESRD patient&#39;s AVF or SAVG hemodialysis configuration, paired exemplary mnemonic markers numbered i are removed from the two horizontally arrayed placeholders  27  contained in marker placement field  16   cc  of placeholder panel  15   c  and restored to the paired exposed circles numbered i on the reproduction of the ESRD patient&#39;s LAVG hemodialysis configuration. Before the next hemodialysis session, the value of x in i={N−(N−x)} is increased by 1, thereby increasing i by 1 and two paired exemplary mnemonic markers numbered i+1 are removed from their correspondingly numbered circles and are placed in the two horizontally arrayed placeholders  27 . During the i+1th hemodialysis session, arterio-venous cannulation occurs at cannulation sites along the ESRD patient&#39;s actual AVF or SAVG hemodialysis configuration corresponding to the paired exposed circles numbered i+1, appearing on the reproduction of the ESRD patient&#39;s AVF or SAVG hemodialysis configuration. Following the i+1th hemodialysis session, the paired exemplary mnemonic markers numbered i+1 are removed from the two horizontally arrayed placeholders  27  and restored to the paired exposed circles numbered i+1. Then, before the next hemodialysis session, the value of x in i={N−(N−x)} is again increased by 1, thereby increasing i+1 by 1 and two paired exemplary mnemonic markers numbered i+2 are removed from their correspondingly numbered circles and are placed in the two horizontally arrayed placeholders  27 , etc.  
         [0148]      FIG. 20  shows image field  23   d  of exemplary site preparation card  20  alongside placeholder panel  15   c  of program  10 . In  FIG. 20 , image field  23   d  contains an exemplary reproduction of a LAVG hemodialysis access configuration. Placeholder panel  15   c  contains inner program field  16   c  holding text instructing a patient with ESRD whose hemodialysis access configuration comprises a LAVG on the use of exemplary mnemonic markers  3 . Marker placement field  16   cc  providing means  13  ( FIG. 4 ) for the removable receipt of exemplary mnemonic markers  3  (not shown in  FIG. 20 ). Inner program field  16   ccc  holds an exemplary manufacturer&#39;s logo. Marker placement field  16   cc  is shown with two horizontally arrayed circular placeholders  27  for the removable receipt of two exemplary mnemonic markers  3  (not shown in  FIG. 20 ). When image field  23   d  contains an exemplary reproduction of a LAVG hemodialysis access configuration, it is used in conjunction with exemplary parallel array of exemplary mnemonic markers  9  shown in  FIG. 17 .  
         [0149]     When image field  23   d  contains an exemplary reproduction of a LAVG hemodialysis access configuration, a set of image identification fields, identified in  FIG. 20  by reference numerals  25   a ,  25   b ,  25   e ,  25   f ,  25   g ,  25   l ,  25   m , is superimposed upon the LAVG hemodialysis access configuration.  
         [0150]     As shown in  FIG. 20 , the set of image identification fields includes: Arterial side image identification field  25   a  that may, for example, contain the words “Arterial side,” or the words “Arterial aspect;” Venous side image identification field  25   b  that may, for example, contain the words “Venous side,” or the words “Vensous aspect;” Elbow image identification field  25   e  that may, for example, contain the word “Elbow;” Wrist image identification field  25   f  that may, for example, contain the word “Wrist;” and, Arterial Start image identification field  25   l  that may, for example, contain the words “Artery start,” or the words “Arterial start.” Arterial Start image identification field  25   l  is proximal to Elbow image identification field  25   e.    
         [0151]     The set of image identification fields further includes Arterial Finish image identification field  25   h  that may, for example, contain the words “Artery finish,” or the words “Arterial finish.” Arterial Finish image identification field  25   h  is proximal to Wrist image identification field  25   f . The set of image identification fields additionally includes Venous Start image identification field  25   g  that is proximal to Wrist image identification field  25   f , and Venous Finish image identification field  25   m  that is proximal to Elbow image identification field  25   e.    
         [0152]     As shown in  FIG. 20 , between Arterial Start image identification field  25   l  and Arterial Finish image identification field  25   h  there is interposed a first approximately linear array of an exemplary six LAVG circles  70 ; and, between Venous Start image identification field  25   g  and Venous Finish image identification field  25   m  there is interposed a second approximately linear array of an exemplary six LAVG circles  80 .  
         [0153]     From the elbow to the wrist, the circles of first approximately linear array of an exemplary six LAVG circles  70  are numbered in ascending order from 1 to 6, the first such circle being about coincident with Arterial Start image identification field  25   l , and the sixth such circle being about coincident with Arterial Finish image identification field  25   m . First approximately linear array of an exemplary six LAVG circles  70  overlies the expanse of the arterial aspect of a LAVG from Arterial Start image identification field  25   l  to Arterial Finish image identification field  25   h.    
         [0154]     From the wrist to the elbow, the circles of second approximately linear array of an exemplary six LAVG circles  80  are numbered in ascending order from 1 to 6, the first such circle being about coincident with Venous Start image identification field  25   g , and the sixth such circle being about coincident with Venous Finish image identification field  25   m . Second approximately linear array of an exemplary six LAVG circles  80  overlies the expanse of the venous aspect of a LAVG from Venous Start image identification field  25   g  to Venous Finish image identification field  25   m.    
         [0155]     In the LAVG embodiment of the invention: 
    [i] Instructional panels  15   a , insert panel  15   b  and placeholder panel  15   c  of program  10 , shown in  FIGS. 9, 11 ,  13 , and inner program fields  16   a ,  16   b  and  16   c  of program  10 , also shown in  FIGS. 9, 11 ,  13 , are adapted to facilitate the rotatable selection, preparation and recollection of hemodialysis cannulation sitess along a LAVG hemodialysis access configuration of a patient with ESRD;     [ii] instruction site preparation field  23   c  of exemplary site preparation card  20 , shown in  FIG. 15   b  is adapted to instruct an ESRD patient having a LAVG hemodialysis access configuration to rotatably select, prepare and recall hemodialysis cannulation sitess along the LAVG hemodialysis access configuration;     [iii] image site preparation field  23   d  of exemplary site preparation card  20 , shown in  FIG. 15   a  is adapted to contain a reproduction of the ESRD patient&#39;s LAVG hemodialysis access configuration; and     [iv] image identification fields  25   a ,  25   b ,  25   e ,  25   f ,  25   g ,  25   l ,  25   m , of image site preparation field  23   d  on exemplary site preparation card  20 , shown in  FIG. 20 , are adapted to facilitate the rotatable selection, preparation and recollection of hemodialysis cannulation sites along the LAVG hemodialysis access configuration of the ESRD patient.    
 
         [0160]     Each numbered circle of first approximately linear array of an exemplary six LAVG circles  70  comprises an indicator of an actual site at which an arterial access hemodialysis needle is cannulated. Each correspondingly numbered circle of second approximately linear array of an exemplary six LAVG circles  80  comprises an indicator of a corresponding actual site at which a venous access hemodialysis needle is simultaneously cannulated.  
         [0161]     Accordingly, the circles of first approximately linear array of an exemplary six LAVG circles  70  and second approximately linear array of an exemplary six LAVG circles  80  identify successively paired representative arterial and venous cannulation sites along the LAVG hemodialysis configuraton and serve as placeholders for correspondingly numbered mnemonic markers of exemplary parallel array  9  shown in  FIG. 17 .  
         [0162]     Correspondingly numbered circles of first approximately linear array of an exemplary six LAVG circles  70  and second approximately linear array of an exemplary six LAVG circles  90  comprise representative arterio-venous cannulation site pairs that are successively employed in an exemplary six successive hemodialysis sessions that comprise an exemplary hemodialysis cycle.  
         [0163]     By “marching” the paired arterial and venous hemodialysis needles down the numbered pathway of corresponding circles along the LAVG, cannulation trauma to the LAVG is evenly distributed over time and repeated cannulation of the same sites is avoided. The longevity of the LAVG is accordingly extended.  
         [0164]     When the LAVG embodiment of the invention is first given to an ESRD patient having an LAVG hemodialysis access configuration, image site preparation field  23   d  on image exemplary site preparation card  20 , already has exemplary twelve mnemonic markers  3  comprising exemplary parallel array  9 , shown in  FIG. 17 , in place within correspondingly numbered circles of first approximately linear array of an exemplary six LAVG circles  70 , and second approximately linear array of an exemplary six LAVG circles  80 .  
         [0165]      FIG. 20   a  shows the appearance of an exemplary reproduction of an LAVG hemodialysis configuration in image site preparation field  23   d  just prior to a first hemodialysis session and also shows the appearance of horizontally arrayed placeholders  27  in marker placement field  16   cc  of placeholder inner program panel  15   c  just prior to a first hemodialysis session.  
         [0166]     As shown in  FIG. 20   a , in advance of the first hemodialysis session of an ESRD patient having an LAVG hemodialysis configuration, two paired exemplary mnemonic markers numbered 1 are removed from their correspondingly numbered circles overlying the reproduction of the LAVG hemodialysis configuration contained in image site preparation field  23   d  on image exemplary site preparation card  20 , and are placed in the two horizontally arrayed placeholders  27  in marker placement field  16   cc  of placeholder inner program panel  15   c.    
         [0167]     Arterio-venous cannulation in the forthcoming first hemodialysis session then occurs at cannulation sites along the ESRD patient&#39;s actual LAVG hemodialysis configuration that correspond to the exposed circles on the reproduction of the ESRD patient&#39;s LAVG hemodialysis configuration, from which the paired exemplary mnemonic markers numbered 1 were removed.  
         [0168]      FIG. 20   b  shows the appearance of an exemplary reproduction of an LAVG hemodialysis configuration in image site preparation field  23   d  just prior to a second hemodialysis session and also shows the appearance of horizontally arrayed placeholders  27  in marker placement field  16   cc  of placeholder inner program panel  15   c  just prior to a second hemodialysis session.  
         [0169]     As shown in  FIG. 20   b , in advance of the second hemodialysis session of an ESRD patient having an LAVG hemodialysis configuration, the two paired exemplary mnemonic markers numbered 1 are restored to their original positions in the correspondingly numbered circles overlying the reproduction of the LAVG hemodialysis configuration contained in image site preparation field  23   d  on image exemplary site preparation card  20 , and the two paired exemplary mnemonic markers numbered 2 are removed from their correspondingly numbered circles and are placed in the two horizontally arrayed placeholders  27  contained in marker placement field  16   cc  of placeholder inner program panel  15   c.    
         [0170]     Arterio-venous cannulation in the forthcoming second hemodialysis session then occurs at cannulation sites along the ESRD patient&#39;s actual LAVG hemodialysis configuration that correspond to the exposed circles on the reproduction of the ESRD patient&#39;s LAVG hemodialysis configuration, from which the paired exemplary mnemonic markers number 2 were removed.  
         [0171]      FIGS. 20   c  through  20   f  respectively show the appearance of an exemplary reproduction of an LAVG hemodialysis configuration in image site preparation field  23   d  just prior to a third, fourth, fifth and sixth hemodialysis session and also shows the appearance of horizontally arrayed placeholders  27  in marker placement field  16   cc  of placeholder inner program panel  15   c , just prior to a third, fourth, fifth and sixth hemodialysis session.  
         [0172]     As shown in  FIGS. 20   c  through  20   f , in advance of the third, fourth, fifth and sixth hemodialysis session of an ESRD patient having an LAVG hemodialysis configuration, two paired exemplary mnemonic markers respectively numbered 2, 3, 4, 5 are respectively restored to their original positions in correspondingly numbered circles overlying the reproduction of the LAVG hemodialysis configuration contained in image site preparation field  23   d  on image exemplary site preparation card  20 , and the two paired exemplary mnemonic markers respectively numbered 3, 4, 5, 6 are removed from their correspondingly numbered circles and are placed in the two horizontally arrayed placeholders  27  contained in marker placement field  16   cc  of placeholder panel  15   c  of program  10  ( FIGS. 20   c  through  20   f ).  
         [0173]     Arterio-venous cannulation in the forthcoming third, fourth, fifth and sixth hemodialysis session then occurs at cannulation sites along the ESRD patient&#39;s actual LAVG hemodialysis configuration that correspond to the exposed circles on the reproduction of the ESRD patient&#39;s LAVG hemodialysis configuration, from which the paired exemplary mnemonic markers numbered 3, 4, 5, 6 were removed.  
         [0174]     Generalizing from the foregoing, an index i={N−(N−x)} may be defined for identifying an ith hemodialysis session in a sequence of N hemodialyis sessions comprising an ESRD patient&#39;s hemodialysis cycle, where x=1, 2, . . . N. When, for example, x=1 and N=6, the first hemodialysis session of the cycle will by identified by i={6−(6−1)}=1. When, for example, x=2 and N=6, the second hemodialysis session of the cycle will by identified by i={6−(6−2)}=2. When, for example, x=N and N=6, the last hemodialysis session of the cycle will by indentified by i={6−(6−6)}=6.  
         [0175]     Following an exemplary ith of N hemodialysis sessions for an ESRD patient having an LAVG hemodialysis configuration, wherein arterio-venous cannulation occurred at cannulation sites along the ESRD patient&#39;s actual LAVG hemodialysis configuration corresponding to paired exposed circles numbered i, appearing on the reproduction of the ESRD patient&#39;s LAVG hemodialysis configuration, paired exemplary mnemonic markers numbered i are removed from the two horizontally arrayed placeholders  27  contained in marker placement field  16   cc  of placeholder panel  15   c  and restored to the paired exposed circles numbered i on the reproduction of the ESRD patient&#39;s LAVG hemodialysis configuration. Before the next hemodialysis session, the value of x in i={N−(N−x)} is increased by 1, thereby increasing i by 1 and two paired exemplary mnemonic markers numbered i+1 are removed from their correspondingly numbered circles and are placed in the two horizontally arrayed placeholders  27 . During the i+1th hemodialysis session, arterio-venous cannulation occurs at cannulation sites along the ESRD patient&#39;s actual LAVG hemodialysis configuration corresponding to the paired exposed circles numbered i+1, appearing on the reproduction of the ESRD patient&#39;s LAVG hemodialysis configuration. Following the i+1th hemodialysis session, the paired exemplary mnemonic markers numbered i+1 are removed from the two horizontally arrayed placeholders  27  and restored to the paired exposed circles numbered i+1. Then, before the next hemodialysis session, the value of x in i={N−(N−x)} is again increased by 1, thereby increasing i+1 by 1 and two paired exemplary mnemonic markers numbered i+2 are removed from their correspondingly numbered circles and are placed in the two horizontally arrayed placeholders  27 , etc.