New study on Buttonhole Safety

[obsidianom]

Higher Infection Risk Seen With Buttonhole AV Fistula Access
December 02, 2013

 


By Anne Harding

NEW YORK (Reuters Health) Nov 28 - Buttonhole needling does not improve arteriovenous fistula (AVF) survival in patients on dialysis, and may increase the risk of infection, new findings show.

In buttonhole needling, an AVF is cannulated in the exact same spot, by the same person, repeatedly so that a scar tissue tunnel track forms and a blunt needle can be used. In the traditional rope ladder technique, the needling site is changed with each cannulation.

In a randomized controlled trial comparing the two techniques in 140 long-term in-center hemodialysis patients, Dr. Jennifer M. MacRae of the University of Calgary in Canada and her colleagues found that buttonhole needling was associated with a lower risk of hematoma formation.

To investigate whether this would lead to improved AVF survival, Dr. MacRae and her team followed patients in the trial for 17.2 months (standard group) and 19.2 months (buttonhole group). Patients received hemodialysis three times per week for four hours. They report their findings in the American Journal of Kidney Diseases, online November 18.

The study's primary outcome, median access survival, was 16.0 months for the standard group and 18.4 months for the buttonhole group (p=0.2). Rates of thromboses and fistulogram were also similar for both groups.

However, while none of the standard-group patients developed infections, twelve of the buttonhole group patients did. Median time to first infection was 11.1 months.

"These results suggest that the use of buttonhole needling in the conventional HD population should be restricted to patients for whom the AVF would be abandoned without the use of buttonhole needling, specifically AVFs with short lengths or in patients with severe needle phobia," Dr. MacRae and her team write. "Whether these results translate to self-needling is unknown. Future research should include a randomized trial exploring use of the buttonhole technique when done by a consistent cannulator, preferably the patient."

In the current study, neither nurses nor patients wore face masks or full-face visors to prevent possible infection transmission, which should be standard when cannulation is performed, Dr. Leslie Spry, a spokesman for the National Kidney Foundation, told Reuters Health.

"I would caution people who are on dialysis who have multiple people cannulating their buttonhole that infection is the main thing to be concerned about," added Dr. Spry, who is medical director of the Dialysis Center of Lincoln in Lincoln, Nebraska.

Buttonhole needling can be useful for patients who receive home dialysis, according to Dr. Spry, who is also medical director for the Lawrence, Massachusetts-based home dialysis company NxStage.

This is because the same person -- either the patient herself or a family member -- is usually doing the needling, Dr. Spry said. "Having a number of different people trying to use a buttonhole is not a good idea. I think the fewer people that cannulate the same fistula each time, the better."

In his own center, he added, patients with buttonholes are encouraged to cannulate their own fistulas. "It's my impression from doing this personally for 15 years that patients who do this on their own to themselves don't have these kinds of results."

SOURCE: http://bit.ly/IsVG7l

Am J Kidney Dis 2013.



 

[obsidianom]

I will add that home dialysis is different and this study only looked at in -center dialysis.  Regardless, it does remind us all that we need to guard against deadly infections all the time if we use buttonholes.
On the positive side for the non-buttonhole patients, the study sowed that sharp rotating needles dont have to damage the fistulas. That was always a concern. This study was only for a year and a half so longer term is still questionable.
Personally I think either technique has its pros and cons. I have switched to sharp rotating sites for my wife and am happier with it . There is less stress with infection worries and having to always worry about damaging the buttonhole and always having to find the exact angle each time. I have found the sharps seem to be developing the fistula better and I am noticing the fistula is getting stronger . I believe the constant rotating and healing the punctures is creating strengthening of the tissue . 

[Hemodoc]

The issue is completely technique related. Stuart Mott will soon publish his results on in-center and home hemo patients. He has achieved significantly better results with buttonhole cannulations than these other groups. Of note, even this Reuters report reported that they didn't even use face masks leading me to question what other adverse techniques were part of the buttonhole routine.

It is way too early to write the requiem for buttonholes, in fact, just the opposite.

[obsidianom]

I agree that buttonholes when done properly have great advantages. However human nature being what it is and medicine being what it is , an inexact art, there are many ways to screw up buttonholes. They are less forgiving then rotating sharps.  In a perfect world with everything being done correctly like Stuart Mott describes( I have taken his webinar) , they work very well and are fairly safe. But again there are so many ways to screw them up and there is little margin for error.
I have 25 years of medicine behind me including being a trained surgeon, so tissue handling is second nature to me. I will tell you all that I had trouble with buttonholes on my wife. Twice we have had infections and elargement of the holes despite my best efforts and following Stuart Motts protocol. I am very careful with everything I do with my wife as she is so important to me. Despite that I had trouble with buttonholes on her and had to return to sharps and rotate. She is doing well with this and the fistula looks better now.
Now I will say that this is only 1 case and it is anecdotal as we say in medicine. It proves nothing. ( other than maybe I am lousy at buttonholes). It may be her tissue or her fistula. It certainly doesnt mean buttonholes are bad. I just have seen the negative side of them personally. I find also that the sharps are easier to work with and take less time to set up than I had with all the careful attention to detail I had with the buttonholes to try to avoid infection.(which happened anyway).
So I simply will say that each of you should do what works best in your own hands. that is true in my field of medicine also. If buttonholes work for you than stay with them. There are some clear benefits to them . But if you cant make them work like in my case, at least this study shows   sharps dont cause damage to the fistula.  They are safe and effective if done correctly.

[Hemodoc]

Stuart Mott has observational data on about 12,000 cannulations using his method without a single infection that he will soon publish. No one has come close to this even with rope and ladder. Technique is the issue with buttonholes. Not everyone is a good candidate for buttonholes, but with proper attention to details, it is absolutely much safer than the latest RCT's suggest.