Buttonhole Cannulation Technique Research Articles

#6792 VASCULAR ACCESS SURVIVAL OUTCOME IN ELDERLY HEMODIALYSIS PATIENTS: A SINGLE-CENTER RETROSPECTIVE STUDY

Abstract Background and Aims Elderly hemodialysis patients usually have lower life patency of vascular access than another age-group. Our center, elderly patients are the most of population of hemodialysis patients. Prior to initiate hemodialysis, planning of first vascular access has been established by patients, nephrologist, and vascular surgeon. The canulation technique for arteriovenous fistula (AVFs) has been determined by experienced hemodialysis-nurse and patient preferences. The aim of this study was to analyze the survival outcome of the access depending on the vascular type in the elderly. Method The study was collected retrospective data between Jan 1, 2013, and December 31,2022. We identified elderly patient (age ≥65) who initiate in-center hemodialysis and first-use vascular access in our center, including arteriovenous fistulas, graft, tunnel-catheter. Outcomes were vascular access patency and subgroup analysis for non-extreme elderly group and extreme (age ≥80) elderly group. A χ2 test, Kaplan-Meier analysis were performed. Results Overall number of elderly patients who initiated hemodialysis are 170: 63 AVFs-first (74% buttonhole cannulation technique), 21 grafts-first and 86 for tunnel-catheters. Mean survival of vascular accesses are higher in AVFs group (78 months in AVFs, 52.5 months in grafts, 53.3 months in tunnel-catheter P = 0.012). The outcome was consistency in the subgroup age 65-80 (80.9 months in AVFs, 47.3 months in grafts, 47.2 months in tunnel-catheter P = 0.005). However, mean vascular access survival did not differ in subgroup age >80 (56.3 months in AVFs, 58.4 months in grafts, 56.4 months in tunnel-catheter P = 0.98). Conclusion In our single center data, vascular access patency of elderly patients was highest in AVFs-first group and AVFs should be the first choice for elderly patients who would initiate hemodialysis especially non-extreme elderly group.

Effect of Nursing Guidelines for Buttonhole Cannulation Technique of Arteriovenous Fistula on Reducing its Complications among Hemodialysis Patients

Effect of Nursing Guidelines for Buttonhole Cannulation Technique of Arteriovenous Fistula on Reducing its Complications among Hemodialysis Patients

Buttonhole Cannulation on a Femoro-Femoral Fistula: A Successful Approach in a Patient with Difficult Vascular Access

Highlights Abstract Vascular access is an essential component for a successful hemodialysis program. Cannulation technique is an important factor for dialysis access survival. For patients with exhausted upper limb vascular access, lower extremity permanent dialysis vascular access (LE-PDVA) is one of the alternatives. The buttonhole cannulation (BHC) technique for LE-PDVA has never been reported in literature. Here we report on a 57-year-old end-stage renal failure patient who had suffered multiple complications related to dialysis access and ended up with exhausted upper limb vascular access. The BHC technique was successfully used on his LE-PDVA for hemodialysis.

Staphylococcus aureus Bacteremia Risk in Hemodialysis Patients Using the Buttonhole Cannulation Technique: A Prospective Multicenter Study

Rationale & ObjectiveArteriovenous fistulas are the preferred access type for hemodialysis. The buttonhole needling technique has become an alternative to stepladder or area puncture. However, an increased risk for infection has been described. The present study examined the risk for infectious complications with different needling techniques.Study DesignProspective multicenter observational cohort study with 5 years of follow-up.Setting & ParticipantsIn-center hemodialysis patients from 5 hemodialysis units in Denmark, dialyzed on a native arteriovenous fistula. 286 patients were included; 144 cannulated with the buttonhole technique.ExposureThe buttonhole cannulation technique was compared to the stepladder or area puncture technique.OutcomesPrimary end points: event rates of access-related Staphylococcus aureus bacteremia and the HR for first access-related S aureus bacteremia. Secondary end points: local infections and access-related S aureus bacteremia–related metastatic infections and mortality.Analytical ApproachTime-to-event analysis using Cox proportional hazards regression to estimate the HR of access-related S aureus bacteremia in buttonhole cannulation compared to stepladder/area puncture. Poisson regression was used for incidence rate ratio calculations.ResultsS aureus caused 48 access-related bacteremias; 43 (90%) in the buttonhole group compared with 5 (10%) in the stepladder/area group. The HR for first access-related S aureus bacteremia was significantly higher for buttonhole cannulation compared to stepladder/area needling (unadjusted, 6.8 [95% CI, 2.4-19.1]; adjusted, 8.4 [95% CI, 2.9-24.2]). The incidence rate ratio for access-related S aureus bacteremia was 6.8 (95% CI, 2.9-16.1), and the incidence rate ratio of local cannulation-site infection without access-related S aureus bacteremia was 3.8 (95% CI, 1.3-15.4) for buttonhole cannulation compared to stepladder/area needling.LimitationsNonrandomized observational design, prevalent hemodialysis patients.ConclusionsAccess-related S aureus bacteremia rates were very high for buttonhole cannulation compared to stepladder/area needling, questioning the use of buttonhole cannulation in routine clinical practice. A restrictive approach to buttonhole use is recommended, with buttonhole cannulation only being used as a second alternative to area technique when stepladder cannulation is not feasible.

Bacteriology of the Buttonhole Cannulation Tract in Hemodialysis Patients: A Prospective Cohort Study

The buttonhole cannulation technique for arteriovenous fistulas is widely used, but has been associated with an increased rate of vascular access-related infections. We describe the frequency and type of bacterial colonization of the buttonhole tract over time and associated clinical infections. A prospective observational cohort study with 9 months of follow-up. 84 in-center hemodialysis patients using the buttonhole cannulation technique at 2 Danish dialysis centers. Bacterial growth from the buttonhole tract and dialysis cannula tip and clinically important infections during follow-up. On 3 occasions 1 month apart, cultures before dialysis (from the skin surrounding the buttonhole before disinfection and from the cannulation tract after disinfection and scab removal) and the cannula tip after dialysis. Patients with positive cultures from the buttonhole tract or cannula tip had repeat cultures within 1 week, along with blood cultures. Growth from the cannulation tract and/or cannula tip at each of the 3 monthly sets of cultures was found in 18%, 20%, and 17% of patients, respectively. 38% of patients had at least 1 positive culture from the buttonhole tract. Sustained growth was detected in 11% of patients, whereas asymptomatic bacteremia was seen in 30% of those with positive buttonhole cultures. Staphylococci species were the most common pathogens (Staphylococcus aureus, 25%; and Staphylococcus epidermidis, 41%). Colonization-positive buttonholes had more localized redness and slightly more tenderness. During follow-up, significantly more access-related infections were diagnosed among those with positive buttonhole cultures (P<0.001). No comparison to area puncture cannulation technique. Blood cultures were obtained only from patients with positive buttonhole bacteriology. Transient or sustained colonization of the buttonhole tract by staphylococci and asymptomatic bacteremia is common in hemodialysis patients, implying a substantial risk for access-related infections among patients using a buttonhole cannulation technique. These findings suggest the possible value of surveillance of buttonhole colonization.

Dual Use of an Arterio-Venous Fistula for Total Parentral Nutrition and Haemodialysis: Potential and Pitfalls

Introduction: We present the dual use of an arteriovenous fistula (AVF) for contemporaneous administration of home parenteral nutrition (PN), and hemodialysis (HD). Case Report: A 52 year old female patient required PN due to short bowel syndrome, following extensive resection for ischemic bowel. After she was rendered dialysis dependent secondary to multifactorial renal failure, a left forearm basilica vein transposition onto the radial artery was undertaken. Venous access for PN was problematic. We commenced home PN via the AVF, using a ‘buttonhole’ technique to cannulate the fistula for both HD and PN. The peripheral administration of PN necessitated reduction in the osmolality, with larger volumes and longer administration times. This required adjustment of the HD regime to compensate.The patient received simultaneous PN and HD at home through the AVF successfully for seven weeks. Unfortunately after this time she suffered a staphylococcal fistula infection with septicemia. Discussion: We have shown that dual use of AVF for HD and PN is feasible, although not without risk. Reduction of osmolality and staggering of PN and HD sessions is required, with administration of PN over longer times. It has been shown that the buttonhole cannulation technique has a higher rate of infection than alternatives, and we propose this may have contributed to our patient’s complication. We believe this report would be helpful if dual use of AVF for PN and HD is contemplated.

Buttonhole Technique or Rope Ladder Technique?

Buttonhole cannulation technique (BH) was introduced by Doctor Twardowsky, a Polish nephrologist, in the seventies and was proposed in Italy and in a great part of Europe in more recent years. It c...

Pro: Buttonhole cannulation of arteriovenous fistulae.

Arteriovenous fistulae remain the access of choice for most hemodialysis patients. However, several factors limit their uptake and long-term patency, resulting in suboptimal prevalent rates in many high-income countries. Patients place considerable value on the avoidance of vascular access complications, pain and disfigurement. The approach to cannulation is a modifiable practice that could improve patient-important outcomes, with buttonhole needling offering some theoretical advantages over the standard rope-ladder and area methods. In this narrative review, we summarize key findings of studies reporting the benefits and risks associated with the buttonhole method, highlighting methodological limitations as well as recent refinements to the technique that may represent potential opportunities for reducing infection risk. We highlight the need for greater certainty surrounding the potential benefits of the buttonhole cannulation technique and propose some directions for future research.

Intradialytic Exercise Results in Improved Quality of Life and Post Dialysis Recovery Time

Intradialytic Exercise Results in Improved Quality of Life and Post Dialysis Recovery Time

Addendum Regarding “Should the Buttonhole Cannulation Technique Be Regarded as the Cannulation Method of Choice for Arteriovenous Fistulas?” (Am J Kidney Dis. 2013;62[1]:7-9)

Since the publication of my editorial entitled “Should the Buttonhole Cannulation Technique Be Regarded as the Cannulation Method of Choice for Arteriovenous Fistulas?” (Lindsay, volume 62, issue 1, pages 7-9) that appeared in the July 2013 issue of AJKD, I have become aware of the trial by MacRae and colleagues that also compared buttonhole cannulation of arteriovenous fistulas with rope ladder needling.1 Both trials compared 140 patients on maintenance hemodialysis therapy who had been randomly assigned to either buttonhole cannulation or rope ladder practice.

Use of an Implantable Needle Guide to Access Difficult or Impossible to Cannulate Arteriovenous Fistulae using the Buttonhole Technique

PurposeThe aim of this work was to assess the safety and efficacy of the VWING Vascular Needle Guide to assist in cannulation of difficult or impossible to access fistulae using the buttonhole cannulation technique.MethodsVWING devices were surgically implanted into patients with difficult to access fistulae. A nondevice site and a device site were used to access the fistula and perform dialysis over a six month period. The device site utilized the buttonhole cannulation technique. The performance of each access site was recorded.ResultsVWING devices were implanted in nine patients. A total of 387 cannulations took place over 1367 study days. The device site was successfully used 94% of the time compared to 77% for the nondevice site. Cannulation success was comparable between the device and nondevice sites. Ease of insertion, pain during insertion and complication rates were also comparable. No interventions were required at the device site to maintain access compared with four interventions for the nondevice access site.ConclusionsThe VWING performed as intended by facilitating required repeated access to the vascular system and access for hemodialysis treatment. The study has demonstrated that the VWING is a potential solution for access to difficult to cannulate fistulae.

Effect of Implementation of Standardized Protocol on Infection Rates in Patients Utilizing the Buttonhole Cannulation Technique for Accessing AV Fistulas

Effect of Implementation of Standardized Protocol on Infection Rates in Patients Utilizing the Buttonhole Cannulation Technique for Accessing AV Fistulas

Buttonhole: What makes the difference

In the last 10 years a great number of contributions have been published on the buttonhole (BH) cannulation technique, mainly by nurses. The word “buttonholing” has gained popularity in the dialysis settings. All studies tried to explore the announced attracting outcomes of this technique: minor pain, less aneurisms, less AVF complications, and easier cannulation for both nurses and patients. Data have been collected for all these areas either as single topic or in multiple-topic data collection analysis, in different settings, with different sample sizes and different observational times. Thanks to this “realistic” approach the challenge of infection could be detected and managed. The variation in the incidence of infections had very low statistical impact, but was relevant for the caring team. What was cited as a “rare alert” by BH founders showed to be, in fact, a real possibility. The present article will refer to the most recent studies, all the variables included, and the related outcomes, and will then try to highlight the issues, related to nursing care, which correlate with positive outcomes of BH performance in hemodialysis patients.

Arterio-venous fistula buttonhole cannulation technique: a retrospective analysis of infectious complications.

BackgroundThere are two main methods of accessing arterio-venous fistulas (AVFs); the ‘buttonhole’ and the ‘rope-ladder’ cannulation technique. Several small studies have hypothesized that the buttonhole technique is associated with increased rates of fistula-associated infection. This study addresses this hypothesis.MethodsA retrospective review of all patients attending a large outpatient haemodialysis clinic was performed. Data were collected on the method of cannulation, infection rates, implicated microorganisms, complications of infection and time on haemodialysis.ResultsA total of 127 patients had received haemodialysis via an AVF: 53 via the rope-ladder technique and 74 via the buttonhole technique. Nine episodes of clinically significant bacteraemia were recorded in the buttonhole group. This equated to a rate of 0.073 bacteraemia events per 1000 AVF days. There were no episodes of bacteraemia in the rope-ladder group. Eight infections were due to methicillin-sensitive Staphylococcus aureus (MSSA); one was due to Staphylococcus epidermidis. Three patients with MSSA bacteraemia subsequently developed infective endocarditis. Five patients who developed bacteraemia events had been undergoing home haemodialysis.ConclusionsThis study highlights the infectious complications associated with buttonhole cannulation techniques. All organisms isolated in our cohort were known skin colonizers. The reason for the increased rates of infection is unclear. Given this high rate of often life-threatening infection, we recommend regular audit of infection rates. We currently do not recommend this technique to our patients receiving haemodialysis.

A RANDOMISED CONTROLLED TRIAL OF BUTTONHOLE CANNULATION FOR THE PREVENTION OF FISTULA ACCESS COMPLICATIONS

This multicentre, prospective, open label, randomised controlled trial was to determine whether buttonhole cannulation technique in new and established haemodialysis fistula reduced complications and prolonged the access life compared to usual practice. Seventy subjects were recruited for this study. Subjects randomised to the buttonhole group had their fistula cannulated by the same staff member for two to four weeks at the same angle and direction with sharp needles. Once the tunnel was developed, blunt needles were used. The control group continued with usual practice (rope ladder rotation technique). Infection at the cannulation site occurred in four patients in the buttonhole group and one in the rope ladder rotation group (p = 0.11). Haematomas at the cannulation site and site pain experienced during the dialysis session were more often recorded for the buttonhole group (p < 0.05). This study showed that buttonhole cannulation resulted more infections, haematoma formation and site pain during dialysis than with the rope ladder rotation group. A further larger scale longitudinal study is recommended.

The impact of extended‐hours home hemodialysis and buttonhole cannulation technique on hospitalization rates for septic events related to dialysis access

Few studies adequately document adverse events in patients receiving long, slow, and overnight hemodialysis (NHD). Concerns about high rates of dialysis access complications have been raised. This is an observational cohort study comparing hospital admission rates for vascular access complications between alternate nightly NHD (n=63) and conventional hemodialysis (n=172) patients established on chronic hemodialysis for at least 3 months. Overall, hospital admission rates and hospital admission rates for cardiac and all infective events are also reported. The NHD cohort was younger and less likely to be female, diabetic, or have ischemic heart disease than the conventional hemodialysis cohort. When NHD and buttonhole cannulation technique were used simultaneously, there was a demonstrated increased risk of septic dialysis access events: incidence rate ratio 3.0 (95% confidence interval 1.04-8.66) (P=0.04). The majority of blood culture isolates in NHD patients were gram-positive organisms, particularly Staphylococcus aureus. Alternate nightly NHD did not significantly change total hospital admissions or hospital admissions for indications other than dialysis access complications, compared with conventional hemodialysis. Our data suggest that buttonhole cannulation technique should be used with caution in patients performing extended-hours hemodialysis as this combination appears to increase the risk of septic access complications. Randomized-controlled trials are needed to confirm these findings.

Randomized Controlled Trial Protocol on Buttonhole Cannulation: A Technique to Reduce Arteriovenous Fistula Access Complications

This multicenter, prospective, open-label randomized controlled trial will be undertaken to determine whether or not the buttonhole cannulation technique in new and established hemodialysis fistula reduces complications and prolongs access life compared to usual practice. A total of 70 subjects will be recruited for this study. Subjects randomized to the buttonhole group will have their fistula cannulated by the same staff member for 2-4 weeks at the same angle and direction with sharp needles. Once the tunnel is developed, blunt needles will be used. The control group will continue with usual practice (rope ladder rotation technique). Measurement of treatment effects will include: (1) quality of life; (2) pain assessment of cannulation; (3) lignocaine use; (4) intradialytic blood flow rate and venous and arterial pressures; (5) dialysis adequacy; (6) cannulation proficiency; and (7) hemostasis time. This study has been designed to provide evidence to help renal clinicians and their hemodialysis patients determine the optimal cannulation technique for prevention of fistula access complications.

“EVERYONE SHOULD BUTTONHOLE”: A NOVEL TECHNIQUE FOR A REGIONAL AUSTRALIAN RENAL SERVICE

The buttonhole, or constant-site, cannulation technique, although used elsewhere, had not been used in North Queensland, Australia, prior to 2005. This paper reports the results from a survey of patients' and nurses' initial experiences with the buttonhole cannulation technique 20 months after its introduction into a renal service in North Queensland. The use of the buttonhole technique increased the ease and decreased the discomfort associated with access cannulation for both patients and nurses; both groups reported less anxiety associated with this technique. The patients were especially pleased with the improved cosmetic appearance and indicated that they would be more likely to become involved in self-care, including self-cannulation. The nursing service has implemented strategies to ensure that buttonhole cannulation continues to be used as one means of arteriovenous fistula access across the region. A current study is examining longer-term outcomes of using the buttonhole technique within this regional service.

Modified buttonhole cannulation technique for fistulae with aneurysmal dilatation

Modified buttonhole cannulation technique for fistulae with aneurysmal dilatation

The salvage of aneurysmal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulators

We describe the St Michael's Hospital (SMH) modified buttonhole (BH) cannulation technique as a method that offers a solution for fistulae with aneurysmal dilatation due to repetitive cannulation in a restricted area. This is a prospective cohort study of 14 chronic hemodialysis (HD) patients with problematic fistulae (marked aneurysmal formation and thinning of the overlying skin, bleeding during treatment, and prolonged hemostasis post-HD) because of repetitive, localized cannulation. Each patient was followed for 12 months. The protocol was as follows: creation of tunnel tracks by 1 to 3 experienced cannulators per patient, using sharp needles. After the tunnel tracks were established and cannulation was easily achieved with dull needles, additional cannulators were incorporated with the guidance of a mentor. Bleeding from cannulation sites during dialysis ceased within 2 weeks and skin damage resolved within 6 months in all patients. Hemostasis time postdialysis decreased from 24 to 15 min. Cannulation pain scores decreased significantly. Access flows and dynamic venous pressure measurements remained unchanged. No interventions were required to maintain access patency. In 2 cases, the aneurysms became much less evident. Complications included one episode of septic arthritis and one contact dermatitis. A third patient developed acute bacterial endocarditis 9 months following completion of her follow-up. The SMH modified BH cannulation technique can salvage problematic fistulae, prevent further damage, and induce healing of the skin in the areas of repetitive cannulation. This technique can be successfully achieved by multiple cannulators in a busy full-care HD unit.