More Data on Buttonhole vs. Rope Ladder cannulation

[obsidianom]

Clin J Am Soc Nephrol. 2014 Jan;9(1):110-9. doi: 10.2215/CJN.03930413. Epub 2013 Dec 26.

Buttonhole cannulation and clinical outcomes in a home hemodialysis cohort and systematic review.

Muir CA, Kotwal SS, Hawley CM, Polkinghorne K, Gallagher MP, Snelling P, Jardine MJ.


Author information




Abstract


BACKGROUND AND OBJECTIVES:

The relative merits of buttonhole (or blunt needle) versus rope ladder (or sharp needle) cannulation for hemodialysis vascular access are unclear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:

Clinical outcomes by cannulation method were reviewed in 90 consecutive home hemodialysis patients. Initially, patients were trained in rope ladder cannulation. From 2004 on, all incident patients were started on buttonhole cannulation, and prevalent patients were converted to this cannulation method. Coprimary outcomes were arteriovenous fistula-attributable systemic infections and a composite of arteriovenous fistula loss or requirement for surgical intervention. Secondary outcomes were total arteriovenous fistula-related infections and staff time requirements. Additionally, a systematic review evaluating infections by cannulation method was performed.

RESULTS:

Seventeen systemic arteriovenous fistula-attributable infections were documented in 90 patients who were followed for 3765 arteriovenous fistula-months. Compared with rope ladder, buttonhole was not associated with a significantly higher rate of systemic arteriovenous fistula-attributable infections (incidence rate ratio, 2.71; 95% confidence interval, 0.66 to 11.09; P=0.17). However, use of buttonhole was associated with a significantly higher rate of total arteriovenous fistula infections (incidence rate ratio, 3.85; 95% confidence interval, 1.66 to 12.77; P=0.03). Initial and ongoing staff time requirements were significantly higher with buttonhole cannulation. Arteriovenous fistula loss or requirement for surgical intervention was not different between cannulation methods. A systematic review found increased arteriovenous fistula-related infections with buttonhole compared with rope ladder in four randomized trials (relative risk, 3.34; 95% confidence interval, 0.91 to 12.20), seven observational studies comparing before with after changes (relative risk, 3.15; 95% confidence interval, 1.90 to 5.21), and three observational studies comparing units with different cannulation methods (relative risk, 3.27; 95% confidence interval, 1.44 to 7.43).

CONCLUSION:

Buttonhole cannulation was associated with higher rates of infectious events, increased staff support requirements, and no reduction in surgical arteriovenous fistula interventions compared with rope ladder in home hemodialysis patients. A systematic review of the published literature found that buttonhole is associated with higher risk of arteriovenous fistula-related infections.


PMID: 24370768 [PubMed - in process]

[obsidianom]

I realize Buttonhole complications are often related to user technique. Many patients do very well with no issues with buttonholes. However I have switched from buttonholes to rope ladder for my wife due to infections and complications with the holes. I read a lot of comments on the Nxstage home dialyzer network about many complications with buttonholes including missing the canal, damage to the sites and infections.
Rope ladder was beleived to damage fistulas, but the research isnt showing this . In a way rope ladder is simpler as you just wipe and cannulate with no need to go through an elaborate prep and worry about the site after.
Whatever works for you the p[atient is most important. Both techniques work.

[noahvale]

^

[obsidianom]

ASAIO J. 2014 Jan-Feb;60(1):95-8. doi: 10.1097/MAT.0000000000000018.

Arteriovenous fistula survival with buttonhole (constant site) cannulation for hemodialysis access.

Kandil H, Collier S, Yewetu E, Cross J, Davenport A.


Author information

Abstract


Buttonhole needling for arteriovenous fistulae (AVF) has increased in popularity among dialysis centers. Concerns have been raised about the risks of infection, so we reviewed our experience of buttonhole needling in 227 adult patients on hemodialysis. The mean buttonhole AVF survival was 27.0 months, in 227 patients, 61.1% male, mean age 63.8 ± 15.5 years, 45.8% with diabetes mellitus, median dialysis vintage 19 months (6.5-42.. Ninety-six patients transferred to rope ladder AVF cannulation, because of cannulation failure in 25%, persistent bleeding at the needling site in 24%, fistula thrombosis in 14%, and infections in 15%. Because of persistent methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant S. aureus (MRSA) colonization, 18.8% discontinued buttonhole needling. Transfer from buttonhole needling was more common for people with diabetes (X = 6.57; p = 0.035), older patients (odds ratio, 0.985; p = 0.007), and persistent MSSA/MRSA colonization (odds ratio, 0.88; p = 0.037). Eleven episodes of suspected buttonhole S. aureus bacteremia occurred giving a bacteremia rate of 2.94 per 100 patient years, and 15 local infections giving an infection rate of 4.01 per 100 patient years. In this large series of buttonhole AVF access, although infection rates were increased, more patients discontinued buttonhole needling because of technical cannulation problems and persistent bleeding from needle tracks.


PMID: 24281124 [PubMed - in process]


LinkOut - more resources

[obsidianom]

I am not anti buttonhole at all. 
My point is there are more and more studies coming out showing the various issues with buttonholes. I have seen these myself.
At least we can use these to guide us in decision making on what type cannulation, but also to those who choose buttonholes , to see where the potential pitfalls are and to try to avoid them.

[noahvale]

^

[obsidianom]

The buttonhole method goes back to I beleive the 1960s or 70s when in a ccommunist country they were running out of needles and had to reuse them and they became blunted. The doctor figured out to go to buttonholes to be able to cannulate with blunt needles and the rest is history.
What I think we need is info on what type of patients would do best on each technique, including co-morbidities, age, sex, location of fistula, length and size of fistula and technique used. That would be so helpful . There are clearly patients that each technique is more appropriate for . So far no one has really looked at all those factors. Perhaps Stuart Mott will answer some of these questions.

[Bill Peckham]

The buttonhole method goes back to I beleive the 1960s or 70s when in a ccommunist country they were running out of needles and had to reuse them and they became blunted. The doctor figured out to go to buttonholes to be able to cannulate with blunt needles and the rest is history.
What I think we need is info on what type of patients would do best on each technique, including co-morbidities, age, sex, location of fistula, length and size of fistula and technique used. That would be so helpful . There are clearly patients that each technique is more appropriate for . So far no one has really looked at all those factors. Perhaps Stuart Mott will answer some of these questions.

Poland was a communust country at the time ... http://www.sfav.org/Publication/AA2010/83.pdf


Dr Twardowski is still very much alive and is very involved with producing the Annual Dialysis Conference. When I first started more frequent HHD in 2001 I used sharps for my buttonholes. Medisystems came out with the first purpose made buttonhole needles in 2002 or 2003.

[noahvale]

^

[Hemodoc]

Stuart Mott has 22,000 cannulations in 4.5 years without a single infection. When his article is published, it will blow these so called "studies" out of the water. Yes, there are concerns about infections but yes it is technique related. It is way too early to write the requiem on buttonholes.

[amanda100wilson]

Peckham has a first name.  it is Bill.