The preference for fistulae as the hemodialysis access of choice has led to a significant number of accesses that are less than ideal for cannulation. Buttonhole cannulation is ideal for such accesses, but the technique for creation provides major challenges. In 12 patients, buttonhole tunnel tracks were created by leaving the polyurethane catheter of a Clampcath hemodialysis needle indwelling for 10 days after the initial cannulation. After each dialysis the catheter was flushed, and dressed with an antibacterial ointment and gauze. Dialysis was carried out via the catheter during that time. After day 10, the catheter was removed, the tunnel track covered with an antibacterial dressing and the tunnel track was cannulated with a dull buttonhole needle at the next dialysis. Successful buttonhole accesses were created in 11 patients after 10 days, the 12th patient required a single sharp needle cannulation before using dull needles. During the first 2 weeks of dull needle cannulation both pain experienced on cannulation and the difficulty cannulating the access were significantly less than in the classical buttonhole technique (P<0.01). Complications during the follow-up period (6 months-1.5 years) included difficulty cannulating with a dull needle (22) and antibacterial agent induced contact dermatitis (4). There was no episode of sepsis or tunnel track infection. Initial cannulation of the fistula using a Clampcath hemodialysis needle, leaving the polyurethane catheter indwelling for 10 days, is a simple, safe, and effective technique for the creation of buttonhole tunnel tracks.

Buttonhole cannulation is a method of cannulation of native arteriovenous fistulae traditionally practiced by self-cannulators. At St Michael's Hospital, this method has been modified to allow its use in problematic fistulae by multiple cannulators. In a busy dialysis unit, the need for a few specific cannulators to establish the tunnel tracks in combination with the variable dialysis schedules creates logistical challenges. A new method of creating tunnel tracks with the use of the BioHole™ device was evaluated. Buttonhole tracks were created in 12 patients using a peg of polycarbonated material with a holder (BioHole™ kit). The peg was inserted into the path left by the hemodialysis sharp needle following the index cannulation. Four of the 12 patients had an alternate access. Buttonhole tracks were successfully created in all the patients, albeit in 2 patients, the initial attempt to establish buttonhole tracks was aborted due to complications and the procedure was rescheduled. Compared with the modified buttonhole technique, pain on cannulation following track creation was significantly less in the BioHole™ group (P < 0.001). Ease of cannulation was significantly improved in the BioHole™ group (P<0.05) when compared with that in thrice-weekly patients using the modified buttonhole technique. Hemostasis postdialysis did not differ between the study groups. The use of the BioHole™ device is effective in the creation of tunnel tracks for buttonhole cannulation, is associated with less pain, and simplifies the logistics of arranging patient and nurses' schedules.

DISCLOSURESIn the past year, TP has received honoraria and consultancy fees from Baxter healthcare and Covidien. JhC has received speaking honoraria and consultancy fees from Baxter healthcare;

Background Little evidence exists regarding optimal peritoneal dialysis (PD) access insertion pathways, benchmarking for patency targets, and definitions of access dysfunction. Methods This quality improvement (QI) project evaluated patients with PD catheters inserted at a single center in Toronto, Canada, following: establishment of PD catheter insertion protocols, a PD access coordinator, PD access operator training, and outcomes reporting. We define primary vs secondary PD catheter dysfunction by presentation before/after initial home PD treatment. We report catheter dysfunction rates, interventions restoring PD catheter patency (interventional radiology [IR] vs advanced laparoscopic [AL]) (embedded vs non-embedded) between 2012 and 2017. Results A total of 297 first PD catheters were inserted between January 2012 and December 2017. Interventional radiology PD catheters ( n = 94) were placed in older patients with greater comorbidities and less prior abdominal surgery than AL-placed catheters. Indications for IR insertion included need for urgent dialysis given resource availability (36.2% [ n = 34]) and prohibitive surgical risk (26.6% [ n = 25]). Interventional radiology-inserted catheters had overall (primary and secondary) dysfunction rates of 17%. Non-embedded AL catheters had 16.1% overall dysfunction. Embedded AL-inserted PD catheters had a 24.6% overall dysfunction rate. Among all dysfunctional catheters, IR manipulation was successful in 31% ( n = 11), and surgical revision was necessary in all unsuccessful cases with either lysis of adhesions or omentopexy to establish patency. Conclusion Our PD catheter QI initiative involved tracking, outcome reporting, defining PD catheter dysfunction and PD access insertion pathway development, yielding important insights into opportunities for program improvement. Multicenter research initiatives are needed to further improve PD access dysfunction definitions and to establish the best benchmarks for these metrics.