Rope-ladder Technique Research Articles

Infection prevention in home dialysis

Purpose of review Among patients with kidney failure, home dialysis modalities, including peritoneal dialysis (PD) and home hemodialysis (HHD) provide several individual and healthcare system benefits over in-center hemodialysis (HD). Infection remains a major source of morbidity and mortality in this population, and a core outcome of critical importance to patients, caregivers, and kidney health professionals. This narrative review provides evidence-based measures for infection prevention among individuals receiving home dialysis, with a particular emphasis on dialysis and access-related infections. Recent findings Patient and care partner education and training is an important and major theme for infection prevention in home dialysis. In PD, identifying and managing modifiable risk factors for infections such as hypokalemia, constipation, use of gastric acid suppressants, and domestic pets, along with the use of antimicrobial prophylaxis, when indicated, can substantially reduce peritonitis risk. Reducing the use of central venous catheters (CVC), and duration of CVC dependence is the most effective means of prevention of HD access-related bloodstream infections in individuals receiving HHD. For arteriovenous fistula cannulation, rope ladder technique is associated with lower risk of infection compared to buttonhole cannulation. Summary Developing and instituting a well structured and evidence-based patient training and education program within home dialysis units is the most important measure in preventing and reducing dialysis and access-related infections. Kidney care providers should be familiar with different infection risk factors among individuals receiving home dialysis.

Reduction in the rate of Permanent Vascular Access Obstruction in Hemodialysis Patients

<p>本專案旨在降低血液透析病人永久性血管通路阻塞率。統計本單位2019年4月至6月永久性血管通路阻塞率為5.37%，高於本單位品質指標監測阻塞率≦3%，經分析原因與護理人員重複施打同位置、病人及主要照顧者未確實執行居家血管通路照護、沒有穿刺位置的標準流程及缺乏團體衛教有關。經由專案小組及跨團隊合作，增設繩梯式打法技術及稽核制度、提供居家血管通路照護圖表及查檢表、製作慢性腎臟病健康管理護照及QR code、舉辦團體衛教及張貼海報。專案推行後，永久性血管通路阻塞率由5.37%降至1.07%，獲得良好成效，不僅發揮團隊功能，且增進永久性血管通路照顧能力，有效降低阻塞率，進而提升更完善的照護品質。</p> <p> </p><p>This project was conducted to reduce permanent vascular access obstruction in patients undergoing hemodialysis. The average rate of permanent vascular access obstruction in our unit from April to June 2019 was 5.37%, which is 3% higher than the quality monitoring index. An analysis of possible causes revealed that repeated injections at one location, the failure of primary care providers to perform home vascular access care, a lack of standardization for locating puncture sites, and a lack of group education are highly associated with high blockage rates. Through team collaboration, the rope ladder technique and audit system were incorporated. Home vascular access care charts and checklists were also provided. In addition, health passports and quick-response codes for chronic kidney disease were provided. Moreover, group health education programs and posters were organized. After project management, the permanent vascular blockage rate decreased from 5.37% to 1.07%. We not only improved the vascular care capacity but also strengthened the relationships between departments. Overall, the rates of vascular blockage decreased.</p> <p> </p>

Hemodialysis nurses' knowledge, attitude, and practices in managing vascular access: A cross-sectional study in Saudi Arabia.

Hemodialysis continues to be the primary approach for renal replacement therapy. Vascular access (VA), particularly arteriovenous fistula or arteriovenous graft, is the preferred technique for establishing hemodialysis access due to its lower risk of infection and central venous stenosis compared to catheters. The aim of this cross-sectional investigation was to examine hemodialysis nurses' knowledge, confidence, and practices in managing VA in Saudi Arabia. This is an online cross-sectional survey study that was conducted in Saudi Arabia between June and August 2023. This study utilized a previously validated questionnaire. Examined dialysis nurses' knowledge, attitude, practice, and self-efficacy pertaining to VA cannulation and evaluation. Binary logistic regression analysis was used to identify predictors of better knowledge of dialysis VA. A total of 197 participants were involved in this study. Around one-third of the study participants (37.0%) reported that they have received specialized training in managing VA. Participants agreement (answered agree or strongly agree) on statements that examined attitudes toward dialysis VA cannulation and management was high and ranged between 75.0% and 93.0%. The majority of participants (97.5%) reported that they perform this assessment. Most nurses (65%) preferred the rope-ladder technique. Participants agreement on statements that examined self-efficacy on dialysis VA cannulation and management was high and ranged between 72.1% and 98.0%. The most commonly agreed upon statement was that "they have confident in performing hemodialysis access (arteriovenous fistula and arteriovenous graft) assessment before cannulation." With 98.0% (answered agree and strongly agree). The mean knowledge score for our study sample was 6.4 (SD: 2.0) out of 12 (53.3%); which reflects marginal-level of knowledge on dialysis VA. Binary logistic regression analysis identified that nurses who have undergraduate degree are 92% more likely to be knowledgeable on dialysis VA compared to others (P < .05). Concerning VA, the level of knowledge among hemodialysis nurses working in Saudi Arabia was inadequate. Nurses who hold an undergraduate degree are presumed to have a more extensive understanding of dialysis VA. Further education programs are necessary for HD nurses to enhance their knowledge of VA, thereby optimizing their professional practices and enhancing the outcomes for their patients.

FISTULOPLASTY FORFAILING AVF - AN INSTITUTIONAL EXPERIENCE

Introduction: Failing AVF can be salvaged by open surgical technique, percutaneous encdovascular or hybrid methods. In this study our institutional experience on balloon fistuloplasty is described. The objective is To investigate the effectiveness of endovascular balloon angioplasty to preserve the patency of failing hemodialysis arteriovenous fistulas (AVF). Materials And Method: 1. Period Of Study - 3 YEARS AUG 2019 TO AUG 2022 2. Total No Of Patients – 20 3. Study method – retrospective observational study Results: In a total of 20 patients 16 cases (80%) were successful with immediate restoration of optimal flow rate during dialysis.At the end of 6 months – 8 were successful. 5 had failed fistuloplasty, 3 – expired. Conclusion:Fistuloplasty is a minimally invasive percutaneous procedure with established safety and efficacy to restore the normal function of AVF.Most common site is Cephalic V puncture sites. It is advised to follow Rope Ladder technique to avoid AVF failure.

A time-saving method of creating AVF buttonholes: indwelling trocar technique.

This study aims to explore the convenience and practicality of the method of establishing buttonholes with indwelling trocars. Compared with rope-ladder technique, buttonhole cannulation has better applicability for haemodialysis patients, and the method of buttonhole establishment is particularly important. Prospective, observational and cohort study. We conducted a 12-month observational study on 30 patients who used sharp needles to establish buttonholes and 33 patients who used indwelling trocars to establish buttonholes, and compared the differences between the two groups in the buttonhole formation time, patient-reported cannulation pain, buttonhole success rate, AVF-related infection and patency of AVF. The study adhered to STROBE guidelines. The buttonhole formation time of the indwelling trocar group is less than that of the sharp needle group (5.48±0.51 vs. 23.23±3.07, p<.01). When the buttonhole was used for the first time, the cannulation pain of the indwelling trocar group was less than that of the sharp needle group (4.94±1.50 vs. 6.03±1.13, p=.002), but there was no significant difference in this result after 1month (sharp needle group with 4.50±0.94 vs. indwelling trocar group with 4.12±1.19, p=.169). Compared with all the buttonholes in the indwelling trocar group were established successfully, there were 5 unsuccessful buttonholes in the sharp needle group (p=.02). Three cases of unsuccessful buttonhole patients in the sharp needle group developed AVF-related infection, this result did not appear in the indwelling trocar group (p=.102). The difference in arterial pressure and venous pressure between the two groups was not significant (p=.061, p=.222). Our new method can help buttonhole patients get less track formation time, less cannulation pain, and less fistula infection, thereby bringing them a more comfortable dialysis experience. The new method used in this study not only meets the needs of patients to protect AVF, but also provides convenience for clinical work. In addition, this study analyzed the causes of the AVF infection in buttonhole patients, and provided directions for future research.

Dialysis efficacy and pain levels in relation to cannulation distance using the buttonhole technique

ObjectiveIn this study, we investigated whether there was any difference in pain and dialysis efficacy when patients who initially entered dialysis with the rope ladder technique were switched to the buttonhole technique.MethodsWe reduced the space between needles and examined the effects on access blood flow rate, dialysis efficacy, and pain levels with BH technique. Forty-four patients participated, 25with dialysis needles placed 5–7 cm apart using the BH technique, and 19 with needles placed 7–10 cm apart.ResultsThere was a significant reduction in the pain sensation in both groups from patients who passed the rope ladder technique to the buttonhole technique from the onset to the sixth month. There was no difference in dialysis efficacy between the patients who passed the lope ladder technique to the buttonhole technique; also, there was no difference in the dialysis efficacy compared to the needle entry interval in two groups of patients who were dialyzed with the BH technique.DiscussionThe BH technique continues to attract interest due to its dramatically reduced pain levels compared to the RL technique and no difference in dialysis efficacy.

Should Buttonhole Cannulation of Arteriovenous Fistulas Be Used? CON.

Fistulas continue to be promoted as the vascular access of choice due to their lower complication rates as compared with catheters (1,2). However, depending on the fistula cannulation method, the infection risk can compared with that of a catheter. Traditionally, cannulation is an area most physicians tend to ignore; instead, the choice and technique of cannulation is routinely left to nurses. However, given the pain, fear, and anxiety with cannulation that most hemodialysis patients experience (3–⇓5), all health care providers should pay more attention to needling. Furthermore, cannulation and its associated mishaps can lead to fistula complications of infection, and decreased patency. The most common method of cannulation among maintenance hemodialysis patients is the rope ladder technique, which rotates needling sites along the full length of the fistula. The area wall technique, where favored regions are repeatedly needled, is actively discouraged due to progressive weakness in the vessel wall and subsequent aneurysm formation (6). Buttonhole cannulation is more often used in home hemodialysis and it was first introduced as a measure to cannulate a fistula with a limited area for needling (7). Buttonhole involves a constant site of needling that, over time, leads to an epithelized track into which a blunt needle is inserted. Since its first introduction almost 50 years ago by Dr Twardoski and his head nurse (Sister Kumara), buttonhole has continued to garner widespread enthusiasm. Support for its use has been mostly promoted by observational data and poor-quality methodology studies showing beneficial effects on pain and fewer needling complications. Nephrology societies (8,9) (renal.org/guidelines) still recommend buttonhole use as a means to reduce pain and increase longevity. In order to promote a novel cannulation technique over the standard of care, there should be evidence of benefit and a lack of demonstrable …

Considerations in Access Cannulation: Traditional and Evolving Approaches.

Needle cannulation of hemodialysis access is the soft underbelly of hemodialysis access care that has remained unchanged for a long time. Cannulation error results in complications such as infiltration, hematoma, subsequent revision procedures, and potential loss of hard-earned access. The "best" cannulation method is contingent upon access type and characteristics along with local expertise. The rope ladder technique of cannulation, characterized by successive rotation of puncture sites with each hemodialysis session, permits sufficient time for healing of prior cannulation sites, and reduction in complications such as bleeding, infection, and aneurysm development. A steeper needle angle, higher blood flow rates, and deep needle tip can lead to wall stress on the posterior wall and up to 10cm from the needle cannulation site. Plastic cannulas provide a viable alternative to metallic needles; they have lower complications and a favorable cost-benefit ratio. There is lack of evidence to support an optimal arterial needle direction configuration. Needle injury may promote intimal thickening, but its effect on access outcomes is currently unknown. Percutaneous creation of arteriovenous fistula presents new challenges in dialysis access cannulation. Point-of-care ultrasound-guided cannulation will likely lead to a paradigm shift in access cannulation. Novel care delivery using cannulation stations is a promising development.

Studio Pilota Randomizzato Controllato: Protocollo Sperimentale Sugli Effetti di Una Medicazione a Rilascio D'argento in Pazienti Incannulati Con Tecnica Buttonhole

Abstract non disponibile (nursing)

Cambio de técnica de punción de la fístula arteriovenosa nativa a partir de los hallazgos ecográficos

Introducción: La técnica de punción en área debe evitarse siendo la técnica escalonada de primera elección en la mayoría de los casos. Objetivo: Identificar a los pacientes portadores de una fístula arteriovenosa nativa que se puncionan mediante la técnica del área y que son susceptibles de cambiarla por la técnica escalonada a partir de los hallazgos obtenidos mediante la exploración mediante ecografía doppler. Pacientes y métodos: Los enfermos del estudio son enfermos tratados mediante hemodiálisis asistida (HD) tres veces por semana que cumplen los siguientes criterios de inclusión: Edad superior a 18 años, prevalentes en programa de HD crónica, con acceso vascular permanente tipo fístula arteriovenosa nativa humeral o radial y puncionado mediante la técnica del área. El método de exploración de la fístula arteriovenosa nativa fue la ecografía doppler portátil. Los parámetros ecográficos se determinaron por duplicado y fueron los siguientes: flujo sanguíneo de arteria nutricia (ml/min), diámetro y profundidad del segmento de vena arterializada que no se punciona (cm). Se diseñó un estudio transversal y observacional que se efectuó durante el mes de enero de 2016. Resultados: De un total de 63 pacientes prevalentes en HD crónica, se registraron: 24 fistulas arteriovenosas protésicas o catéteres y 39 fístula arteriovenosa nativa. De éstas, sólo 9 se puncionaban mediante la técnica de área (14,4%): 6 humerobasílicas y 3 humeroperforantes (edad media 73,0±13,3 años, 77,7% con alguna comorbilidad). Respecto al resultado de los parámetros ecográficos, se objetivó una media de 0.7± 0.3 cm de diámetro y 0.5± 0.3 cm de profundidad en el segmento de vena arterializada que no se punciona y el flujo medio de la arteria humeral fue de 1309,9± 966 ml/minuto. En la mayoría de los mismos fue posible utilizar directamente la técnica escalonada gracias a la ampliación de la zona puncionable de la vena arterializada utilizando la ecografía doppler. Y en dos enfermos, fue imprescindible la superficialización previa de la misma. Por tanto, todos los casos de técnica del área pueden ser potencialmente cambiados por la punción escalonada. Conclusión: 1) Se ha registrado una baja incidencia de utilización de la técnica de punción en área en nuestra Unidad de HD. 2) Según los resultados de nuestro estudio, es factible cambiar la técnica de punción en área por escalonada en todos los casos a partir de los parámetros morfológicos y funcionales obtenidos en la fístula arteriovenosa nativa. 3) La ecografía doppler portátil utilizada "in situ" en la sala de HD es una herramienta valiosa que permite optimizar la técnica de punción de la fístula arteriovenosa nativa.

A enfermagem e o ser no mundo em terapia hemodialítica: estudo fenomenológico

Aims: to comprehend the being-in-the-world while undergoing haemodialysis, aiming the offer of human care in its aesthetic dimension; to catalogue the perceptions of Chronic Kidney Disease (CKD) patients on the aesthetic dimension of their bodies regarding the care received while on haemodialysis; to suggest nursing care actions based on perceptions of the corporeity of the being-in-the-world during haemodialysis in an aesthetic dimension. Method: This is a phenomenological, descriptive-exploratory and qualitative study. Study setting: a haemodialysis clinic located in the state of Rio de Janeiro. Population of the study: 163 patients of the clinic. Patients who are over eighteen years old and undergoing haemodialysis, performed using the rope-ladder technique for at least two years, will be included in the study. A sample of 80 subjects is estimated, which is the corresponding number to the total of patients being submitted to the rope-ladder technique. They will be personally invited to take part of the research. Data will be collected through phenomenological interviews and analysed according to Amedeo Giorgio's method.

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...

Con: Buttonhole cannulation of arteriovenous fistulae.

Successful cannulation of arteriovenous fistulas (AVFs) using a safe and effective technique that minimizes patient harm is a crucial aspect of haemodialysis treatment. Although the current standard of care for many years has been the rope-ladder technique (using sharp needles to cannulate rotating sites across the entire AVF), a number of enthusiasts have recently advocated for the alternative method of buttonhole cannulation (using blunt needles to repeatedly cannulate the same site via a healed track) on the basis of putative, as yet unproven benefits. In this article, we review all available observational studies, randomized controlled trials, and systematic reviews and meta-analyses that have compared the clinical outcomes of buttonhole and rope-ladder cannulation of AVFs. These studies clearly and consistently demonstrated that buttonhole cannulation causes significant and serious infectious harm to haemodialysis patients, especially in the home setting. No strategies or treatments have been proven to effectively mitigate this hazard of buttonhole cannulation. Moreover, buttonhole cannulation is associated with a higher rate of abandonment and has not been shown to have any proven benefit compared with the rope-ladder method. Specifically, buttonhole cannulation has not been shown to reduce cannulation-related pain, improve vascular access survival, reduce vascular access interventions, reduce haematoma formation, improve haemostasis or reduce aneurysm formation. Consequently, rope-ladder cannulation should remain the standard of care and buttonhole cannulation should only be used in rare circumstances (e.g. short segment AVFs where the only alternative is a haemodialysis catheter).

Moderator's View: Buttonhole cannulation of arteriovenous fistulae: great caution is warranted.

Potential advantages of buttonhole (BH) cannulation over the standard rope-ladder technique have been claimed on the basis of small sized, potentially biased observational studies with a relatively short follow-up. On the contrary, randomized controlled trials (RCTs) show inconclusive or conflicting results. The uncertain benefit must thus be weighed against a definite increase in the infectious risk with the BH technique, which may not be completely abolished by preventative strategies. Awaiting the results of long-term studies (>2-3 years follow-up), the widespread use of the BH technique is not warranted, especially in busy in-centre haemodialysis (HD) settings with many rotating nurses. In our experience, the BH technique has been implemented safely in a self-care HD unit, presumably because of the limited number of cannulators and, in the case of self-cannulating patients, direct supervision by a small team of nurses. Units (and patients) willing to use the BH technique should be aware that BH is an extremely demanding technique and requires constant and strict adherence to the protocol. Regular monitoring of infection rates is recommended. Additional RCTs are clearly warranted, together with large-sized observational studies with multivariable adjustment.

Buttonhole Versus Rope-Ladder Cannulation of Arteriovenous Fistulas for Hemodialysis: A Systematic Review

The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks and benefits of the buttonhole compared with the rope-ladder technique is uncertain. A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded). HD patients (both in-center conventional HD and home HD) using an AVF for vascular access. We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique. Buttonhole versus rope-ladder cannulation technique. The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality. Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference,-0.76 [95%CI,-1.38 to-0.15] standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 [95%CI,-0.76 to 1.43] standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections. Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes. Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs.

Quality indicator of caring related to the buttonhole technique: an exploratory study

This is a project of dissertation of the Academic Master’s Program in Health Care Sciences of Fluminense Federal University. General aim: To discuss the buttonhole technique as an indicator of the quality of health care service offered to patients in hemodialysis therapy in a private clinic setting, which the clientele coming from the Brazilian Unified Health System (SUS, in Portuguese). Specific aims: To describe the buttonhole technique offered to the patients under hemodialysis therapy; to identify the results of this practice over the last three years, comparing the outcomes against the rope ladder technique. Method: This is an exploratory, documentary and descriptive study, which has adopted a quantitative-qualitative approach, which explores the use of the buttonhole technique, looking for the results directly from the clients. The data was collected between January and April 2014. The results from 64 patients were compared, based on a questionnaire to indicate the quality of the nursing assistance provided. The information was analyzed through the use of inferential statistics.

The Buttonhole Technique for Fistula Cannulation: Pros and Cons

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.

The Effect of Buttonhole Cannulation vs. Rope‐ladder Technique on Hemodialysis Access Patency

The rope-ladder (RL) technique is the most common technique used for cannulation of arteriovenous fistulae (AVF). Buttonhole cannulation (BHC), or constant-site technique, is recommended by the National Kidney Foundation's Kidney Disease Outcome Quality Initiative (NKF/KDOQI) vascular access guidelines. We compared outcomes of primary patency, episodes of bacteremia, access blood flow (Qa), and quality of life (QoL) scores between RL and BHC patients. Using a prospectively collected, vascular access database, a total of 45 prevalent dialysis patients using BHC were compared with 38 patients using the RL technique over a median of 12months (inter-quartile range: 4-27months). The two groups did not differ significantly in demographics except that diabetes was more common in those using BHC as compared to rope-ladder (69% vs. 34%; p=0.002). Risk factors associated with lack of primary patency were age (hazards ratio [HR]=1.02 per decade; 95% CI: 1.00-1.03; p=0.04) and female gender (HR=1.92; 95% CI: 1.08-3.40; p=0.03). Use of the buttonhole technique was not associated with improved primary patency (HR=1.22, 95% CI: 0.65-2.28; p=0.53). Episodes of bacteremia and mean scores from KDQOL-36 did not differ significantly between the groups. This study demonstrates for the first time that BHC use is not associated with improved access patency.

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.

Clinical Utility of the Buttonhole Technique Using Biohole™ in Hemodialysis Patients

Background/Aims: Buttonhole cannulation has been popular because it provides an easy puncture, is less painful, and requires less time for hemostasis. However, the technique requires a skilled staff and a long time to form the tract. A new buttonhole technique using Biohole(TM), which shortens the time needed for tract formation, has been introduced in Europe, North America, and Japan. Methods: We prepared a cannulation tract using the buttonhole technique and Biohole(TM) over a two-week period and compared the 12-week outcomes between patients who underwent the rope-ladder versus buttonhole techniques. Results: The 40 patients (27 males) had a mean age of 49.1±14.2 years. Thirteen and 27 patients were cannulated with the rope-ladder and buttonhole techniques, respectively. Patients who underwent the buttonhole technique had more initial pain than did those who received the rope-ladder technique (p=0.044). The Biohole(TM) procedure improved puncture pain (5.6 vs. 3.4, p=0.003) and shortened hemostasis time (1.8 vs. 1.3, p=0.001). Over a two-week period, patients using Biohole(TM) experienced dislocation (20.8%), bleeding at peg sites (8.6%), and pain during peg change (2.4%). Over the 12 week study period, patients who underwent the buttonhole technique had insignificantly less pain than did those who received the rope-ladder technique (p=0.088), but the former had less bleeding time than the latter (p=0.000). One patient who received the buttonhole technique experienced one episode of infection (p=0.327). Conclusions: The new buttonhole technique using Biohole(TM) is safe and useful in the short term. A long-term, larger, multicenter study is required to confirm these results. (Korean J Med 2012;82:307-312)