To Buttonhole or Not? Strong opposing views.

[swramsay]

I am new to dialysis (4 months) and will begin using my fistula in a couple of weeks. I am confused by strong opposing views over using the buttonhole technique. I am young(ish) at 51, active and keep up with our 10-year-old son. I am also somewhat vane in the sense that I don't want my fistula to be a huge, ugly ballooning growth on my upper arm if at all possible. I do understand not letting anyone else do your cannulation. My vascular surgeon, who is well respected in the Seattle area, is adamantly opposed to buttonhole. So much so that she refuses to take patients that do that. She insists that buttonholing ruins great fistulas and has had many, many patients sent to her to repair their fistulas for that reason. she is very intelligent and respected. I am strongly inclined to believe her. She wants me to use a sharp needle in a different spot along my fistula for a year thus creating a straight, clean access scar along the entire length of my vein. I can see how that would provide strength to the vein. She explained that with buttonholing, ballooning veins happen because the buttons are tougher and won't expand like the rest of the weaker veins.  I do understand that buttonholing is more convenient and less painful initially but convenience and lack of pain are not a priority consideration for me. Maintaining a strong fistula for the rest of my life and one that is not damaged or becomes grotesque to look at is more important.

I am currently at a Davita center. The first 2 months I was with Northwest Kidney. Both dialysis centers are strongly in favor of buttonholing but cannot answer why other than it's easier. I have looked through some of the posts containing buttonholing but have not found any discussion about the reason it's better other than convenience for the most part.

I would love for the most convenient and less painful method (buttonhole) to be the best all around so if anyone can give a great argument for that technique, I'd appreciate it.

thanks!

[charee]

I did buttonhole for nearly 2 years without any problems .I started straight with buttonhole so i can't comment on the ladder technique . everything i have been told is that its better for the life of your fistula. do a search on buttonhole as there are a few good  threads on them. Good luck

[silverhead]

I would tend to agree that a Buttonhole is better, but feel that it is best to get a year or so of Laddering to build up the Fistula first. I have been cannulating Sharon at the same sight for a year and a half with no problems or infiltrations. depending on the depth of the arteries and veins it will "grow" up and out no matter what, they are life giving access points and she is proud of the sight of them.....

[nursewratchet]

We do both at my center.  You have to strengthen the fistula before you can buttonhole.  The ladder is excellent for just that.  Our surgeons suggest both, and that's what we do.  Once fully developed and strong walls are in place, then the buttonhole can be started.  It is thought to strengthen the life of the access.  Always have the same person "start" the buttonhole, for at least a month.  If you don't want to do the buttonhole, ever, remember, it's patient choice, the center can't dictate.  Good Luck!

[Wallyz]

Get a second opinion.  Neusel at Virginia Mason is really good.  Doubled button holes are the gold standard,a nd your vascular surgeon's insistence is coutner to consensus in the field.

[petey]

With perm caths, PD caths, grafts, and fistulas, my husband Marvin has done a little bit of everything when it comes to cannulation/connection for treatments.  He has an AV fistula that he's now using (been using the same one for almost four years -- longest access he's ever had   ).  When he first got this fistula, he was in-center, so they used the sharp/ladder technique on his current fistula.  We've been doing home hemo for 18 months, and we've created and used one set of buttonholes (still using these currently) on this same fistula.  Marvin says he much prefers the buttonholes, even though there is still pain involved for him with each cannulation (there's a nerve that runs right across his arterial -- no way around it -- lidacaine creme is his best friend).  We were told (and have researched) that buttonholes will extend the life of the fistula -- that's why we use it.  Now at almost 14 years on dialysis and 20+ access of all types, we want to make every one count and last just as long as we can.  Unfortunately, the fistula Marvin has now was "made" by taking a vein out of the back of his arm and strengthening with a vein transplanted from his thigh because he had run out of places to put an access (except in the leg -- which, Marvin considers, is his last option).

As for the look of a working fistula, there's not much way around the protruding, raised, snake-or-balloon-like look to it.  When Marvin was using sharp/ladder technique, his fistula became raised -- or whatever you want to call it.  I can't tell that using buttonholes for the last 18 months has made it any more raised than it already was with the ladder technique (2 1/2 years with this).  

Marvin is an extremely good-looking man, and he is very attentive to "looking sharp" (though not vain, in my opinion).  However, we both think that his fistula arm is absolutely gorgeous; we call it his "magic fistula."  Marvin wears short sleeves all the time and never tries to "hide" his fistula.  Most of our friends (and ALL of the nieces and nephews) usually ask Marvin to feel his thrill (although the little ones -- including the kids on Marvin's youth baseball team -- call it his "bumblebee").  If Marvin meets someone who doesn't know he's on dialysis and they ask, "What's wrong with your arm?", he'll say, "Isn't it beautiful?  It's my access for my dialysis treatments..." and then Marvin takes the conversation on to tell about dialysis, kidney failure, organ donation, etc.  Marvin is proud of his fistula and proud that he's survived so long.

Beauty is in the eye of the beholder, and, to us, Marvin's arm -- raised, protruding, and all -- is absolutely beautiful!  It is a part of him, a part that we have accepted, embraced, and love.

[del]

Hubby has done both the ladder and buttonholes. He much prefers buttonholes.  We were told that buttonholes extend the life of the fistula.  All the research I have done say the same thing. Whatever you do you are going to notice the fistula and people are going to ask questions.  Hubby is like Marvin he doesn't mind and wears short sleeves all the time. He will explain to people what the fistula does!!  He has been using the same fistula since 2000. He used sharps and the ladder for 6 years and for the past 2 1/2 years we have been doing buttonholes. he is just using the one set of buttonholes.  His arm is raised a bit. Looks like a garden hose stuck on his arm but he has no ballooning.  Get a second opinion.

[swramsay]

sounds like the laddering helps initially. Makes sense to do buttonholes after that. Men seem to do better (for the most part) with the physical aspects of treatments. They also do better with hair loss from chemo. Battle scars on men have always been more accepted on men (and even considered attractive!) then on women.

thanks for the information.

[monrein]

I did 5 years of hemo starting in 1980 and I cannulated myself the entire time using the laddering technique.  It worked beautifully and I had no problems whatsoever but I was very strict about always going in the spot just behind the previous one.  No bulges at all but of course the vein got bigger.  After transplant it clotted and went flat.  I never even heard of buttonholes at that time.
This time, I started back with an upper arm fistula in April, laddered for the first four months or so and have been using one set of buttonholes since then with no trouble.  I use only blunts and no one touches my fistula but me.  At my clinic, I would say that the women are far braver about the needles than the men in general but everyone gets used to them after a while. 

[swramsay]

For everyone who does their own needles, who trained you? I'm not comfortable with the dialysis center staff - most of whom were hired off the street and trained on the job.

[monrein]

Initially, a very skilled nurse did my needling and I watched carefully and she described what she was feeling for and doing.  I then started doing the feeling and would tell her how I would approach it.  Then I just did the needling as she talked me through it.  This time around, I watched again and soon felt ready so off I went.  After about two weeks I didn't need the nurse to stand by me as I did it and I was on my own.  When I was comfortable with that I moved on to hooking myself up and also taking myself off.  At first I followed some written instructions but now I'm completely nurse free, unless I drop something during my run.  I can also deal with most alarms and reset the machine.  I love the independence of it.
I did home hemo for 5 years before and I used two very different machines, one in Nova Scotia where I was working at the time and another here in Ontario where I spent the summers.

You Tube has some videos of people doing their own needles.

[petey]

Marvin doesn't self-cannulate (he still can't even look when the needles are going in -- even after all these years).  However, when we were training for home hemo and establishing his buttonholes, the "expert" nurse from the floor came back to the training room and worked with me to establish the buttonholes.  At first, she had me stand over Marvin and "fake" stick him to see how big my hands were, what angle I'd use because of my height, etc.   She did the initial six sticks (sharps in same location), and then I took over with blunt needles.  She was a pro!  (And, by the way, that was the FIRST time I had ever stuck anybody with a needle -- I'm a high school teacher.)  It was a piece of cake (though I was nervous to start with).  I have also had to use sharps on his buttonholes several times (he's a quick healer and after his day off every week, we occasionally have to use a sharp to open the track back up -- usually only once a month or so).  We sometimes see this same nurse when we go for Marvin's monthly check-ups at the clinic and she always remembers us (though the only time we ever saw her before was when we were establishing the buttonholes) and she wants to know how Marvin is doing on home hemo  --    -- Miss Diane, Wilmington, NC, DaVita is the best in the world!!!!

[nursewratchet]

For everyone who does their own needles, who trained you? I'm not comfortable with the dialysis center staff - most of whom were hired off the street and trained on the job.

     The preceptor,or trainer at the clinic will most likely train you.  Or you can ask the Charge Nurse who the best cannulator in the clinic is.  They'll be good.  Everyone is trained on the job, even the ones who are the best at the job.  It'll be fine.  Good Luck...

[nursewratchet]

Marvin doesn't self-cannulate (he still can't even look when the needles are going in -- even after all these years).  However, when we were training for home hemo and establishing his buttonholes, the "expert" nurse from the floor came back to the training room and worked with me to establish the buttonholes.  At first, she had me stand over Marvin and "fake" stick him to see how big my hands were, what angle I'd use because of my height, etc.   She did the initial six sticks (sharps in same location), and then I took over with blunt needles.  She was a pro!  (And, by the way, that was the FIRST time I had ever stuck anybody with a needle -- I'm a high school teacher.)  It was a piece of cake (though I was nervous to start with).  I have also had to use sharps on his buttonholes several times (he's a quick healer and after his day off every week, we occasionally have to use a sharp to open the track back up -- usually only once a month or so).  We sometimes see this same nurse when we go for Marvin's monthly check-ups at the clinic and she always remembers us (though the only time we ever saw her before was when we were establishing the buttonholes) and she wants to know how Marvin is doing on home hemo  --    -- Miss Diane, Wilmington, NC, DaVita is the best in the world!!!!

    Miss Diane in NC just had her day made.  That's SOOO cool for a nurse to get good feedback from patients!!! Thanks for that.

[swramsay]

I have had some excellent nurses over the years. I know I will find some in the nephrology/dialysis world as well - hopefully soon.