2/5/2015

ASDIN 2015 1

Buttonholes:Should we use them?

Arif Asif, MD, FASN, FNKF

Standard AVF Needles

Cut skin, Sub Q tissue and Vein withneedle insertion

Can cut the vein and cause an infiltrationonce inside the vein

Can also cut the same with needleremoval if the needle is compressed as theneedle is being removed (patients willcomplain of pain with the needle removal)

Slide Courtesy: Deborah Brouwer

“One-site-itis”

“One-site-itis” occurswhen you stick theneedle in the samegeneral area, dayafter day.

Causes aneurysm andstenosis formation.

Areapuncture

sitetechnique

AKA“One-site-it

is”

Slide Courtesy: Deborah Brouwer

Vesely TM: J Vasc Interv Radiol 16:1301-1306, 2005

Buttonhole Needles

Blunt or “Dull” edges

Will not cut Skin, Sub Q tissue or Veinwith needle insertion

Will advance into the scar tunnel track likea pieced earring enters the earring tunneltrack

Slide Courtesy: Deborah Brouwer

Buttonhole Needles

Can not cut skin, Sub Q tissue and Veinwith needle insertion

Can not cut the vein and cause aninfiltration once inside the vein

Can not cut with needle removal if theneedle is compressed as the needle isbeing removed

Slide Courtesy: Deborah Brouwer

2/5/2015

ASDIN 2015 2

Buttonhole History

First appeared in Poland in 1977

Dr Twardowski developed the technique in Poland over 25 yearsago

Dialysis supplies including AV fistula needle were very limitedsupplies.

AV fistula needles were reused for multiple cannulations.

The needles became dull after repeated use and would not cut theskin

The “dull” needles would enter smoothly if the exact samecannulation site was used (same skin entry, same angle of entryand same vessel entry angle).

Buttonhole technique was used to solve dull needle challenge

Slide Courtesy: Deborah Brouwer

What is buttonholetechnique?

Buttonhole technique is a cannulationmethod where an individual cannulatesthe AV fistula in the exact same spot, atthe same angle and depth of penetrationevery time.

A scar tissue tunnel tract developsallowing for the use of a buttonhole fistulaneedle.

Slide Courtesy: Deborah Brouwer

AVF Buttonhole Technique

Slide Courtesy: Deborah Brouwer

Cannulation Issues

Pain

Cannulation injuries and hematoma

Infection

Stenosis and thrombosis

Pseudoaneurysm formation.

Buttonholes and Infection

N=33.

Patients were followed-up for 18 monthsand pain, cannulation injuries and AVFinfection were assessed.

A significant reduction in pain andcannulation injuries was found.

3 AVFs developed infection at thecannulation site.

Verhallen et al: Nephrol Dial Transplant 2007

Buttonhole and Infection

N=21

47% had increased incidence of clottingafter the initiation of cannulation using thebuttonhole technique.

Infection of the AVF was observed in 10%of the patients.

Reduction of pain and cannulation injuries.

Silva et al: J Brasil Nephrol 2010

2/5/2015

ASDIN 2015 3

Buttonhole and Infection

177 patients (aged 70.4±11.5 years) with 193AVFs were analyzed over 186,481 AVF-days.

The incidence of infectious events for conventionalcannulation was 0.17/events /1000 AVF days.

The incidence of infectious events increased afterthe switch to the buttonhole method to 0.43events/1,000 AVF-days (P=0.003).

Labriola et al: Am J Kidney Dis 2011

Buttonholes and Infection

Randomized clinical trial.

N=70.

fistula cannulated for two to four weeks at thesame angle and direction with sharp needles(n=35).

Once the tunnel was developed, blunt needleswere used (n=35).

The control group continued with usual practice.

Pain, hematoma and infection were assessed.

Chow et al: Journal of Renal Care 2011

Buttonholes and Infection

Results: Infection at the cannulation siteoccurred in four patients in the buttonholegroup and one in the rope ladder rotationgroup (p=0.11).

Hematomas and site pain experiencedduring the dialysis session were moreoften recorded for the buttonhole group(p=0.05).

Chow et al: Journal of Renal Care 2011

Scab Removal and Cannulation

Don’t flip the scab offwith the needle you willuse for cannulation—this contaminates theneedle

Don’t use a sterile needle—you could cut thepatient’s skin and youwould also need a sharpscontainer nearby

Don’t allow patients topick at their scabs

Do use aseptic scabremover, or Soak two 2″ x 2″s with sterile

saline and apply over thescabs; or

Moisten 2″ x 2″s with alcohol-based gel; or

Have patient tape an alcoholsquare over sites prior todialysis

Have patient apply moist,warm washcloth to scab siteprior to arriving at dialysis tofacilitate scab removal

Buttonhole and Infection

177 patients (aged 70.4±11.5 years) with 193AVFs were analyzed over 186,481 AVF-days.

The incidence of infectious events for conventionalcannulation was 0.17/events /1000 AVF days.

The incidence of infectious events increased afterthe switch to the buttonhole method to 0.43events/1,000 AVF-days (P=0.003).

Labriola et al: Am J Kidney Dis 2011

2/5/2015

ASDIN 2015 4

Buttonhole and Infection

177 patients (aged 70.4±11.5 years) with 193AVFs were analyzed over 186,481 AVF-days.

The incidence of infectious events for conventionalcannulation was 0.17/events /1000 AVF days.

The incidence of infectious events for buttonholessignificantly decreased to 0.15 events/1,000 AVF-days; P=0.04) after the employment of qualityimprovement educational workshops.

Labriola et al: Am J Kidney Dis 2011

CONCLUSIONS Skin tunnel track provides bases for

repeated use of a cannulation site.

Careful aseptic technique is required.

Logically, it should reducepseudoaneurysm formation.

There does not seem to be an increasedrisk of infection as demonstrated by arandomized study.