The Buttonhole Technique for Fistula Cannulation: Pros and Cons

Abstract

The most common method of arteriovenous fistula (AVF) cannulation is the standard rope-ladder technique. An alternative needling possibility is the buttonhole technique (BHT), by which needles are inserted exactly at the same position. Although earlier studies associated the BHT with a reduction in pain and hematoma formation, more recent randomized studies show no reduction in pain and an increased risk of local and systemic infection. However 1 trial with a follow-up of up to 1-year showed a better survival of the AVFs with the BHT, and did not confirm the increased risk of infection in the BHT group. The abovementioned study is the first well-constructed randomized clinical trial that directly compares the BHT with the use of BioHole peg, helping the development of the fibrous tract, and the rope-ladder cannulation techniques. In any case, the successful implementation of the BHT requires the dialysis nurse to develop a high level of knowledge and several specific skills; it also requires frequent monitoring and a continuous evaluation and education regarding the use of the technique. We here emphasize the need for retraining the staff at specified time intervals to ensure that the proper technical skills are maintained. Therefore, in order to prevent BHT complications, a strict cannulation protocol should be followed. Given the potential increased risk of infections associated with BHT, a better understanding of its actual benefit is needed. Clearly, further rigorous studies are needed, and these should focus on the role of the polycarbonate peg and of topical antimicrobial prophylaxis.