The Effect of Buttonhole Cannulation vs. Rope‐ladder Technique on Hemodialysis Access Patency

Abstract

The rope-ladder (RL) technique is the most common technique used for cannulation of arteriovenous fistulae (AVF). Buttonhole cannulation (BHC), or constant-site technique, is recommended by the National Kidney Foundation's Kidney Disease Outcome Quality Initiative (NKF/KDOQI) vascular access guidelines. We compared outcomes of primary patency, episodes of bacteremia, access blood flow (Qa), and quality of life (QoL) scores between RL and BHC patients. Using a prospectively collected, vascular access database, a total of 45 prevalent dialysis patients using BHC were compared with 38 patients using the RL technique over a median of 12 months (inter-quartile range: 4-27 months). The two groups did not differ significantly in demographics except that diabetes was more common in those using BHC as compared to rope-ladder (69% vs. 34%; p = 0.002). Risk factors associated with lack of primary patency were age (hazards ratio [HR] = 1.02 per decade; 95% CI: 1.00-1.03; p = 0.04) and female gender (HR = 1.92; 95% CI: 1.08-3.40; p = 0.03). Use of the buttonhole technique was not associated with improved primary patency (HR = 1.22, 95% CI: 0.65-2.28; p = 0.53). Episodes of bacteremia and mean scores from KDQOL-36 did not differ significantly between the groups. This study demonstrates for the first time that BHC use is not associated with improved access patency.

Buttonhole Versus Rope-Ladder Cannulation of Arteriovenous Fistulas for Hemodialysis: A Systematic Review

“…[6][7][8][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] Study and Participant Characteristics There was significant heterogeneity among studies (Table 1). Of the 23 studies included, 5 were randomized controlled trials (RCTs) 7,19,21,23,29,38 (the second study by MacRae et al 38 was a long-term follow-up of their original RCT 19 ), while the rest were observational studies of various designs: prospective cohort, 8,28,37 retrospective cohort, 20,30,34 prospective before-after, 27,31,35 retrospective beforeafter, 6,22,25,26,32,36 or cross-sectional. 24,33 Eight of 23 studies did not have an explicit or even implicit prespecified primary outcome.…”

“…The association between local and/or systemic infection and cannulation technique was described in 15 studies (Table 3). [6][7][8][19][20][21][22][23]25,29,30,32,34,36,37 Owing to the heterogeneity of the case definition of infectious complications, we have not pooled results. However, all 10 studies (of which 4 were RCTs) including exclusively conventional facility-based HD patients reported a trend toward an increase in infectious events among buttonhole cannulators.…”

Buttonhole Cannulation of Arteriovenous Fistulas in the United States

“…In 2014, Chan et al compared complications over a 1-year period associated with the BH and RL techniques from a single center in Wisconsin, using a prospectively collected database (18). Patient demographic and clinical characteristics were similar between the BH (n=45) and RL (n=38) groups, with the exception of diabetes mellitus, which was more prevalent in the BH group (69% vs. 34%, p=0.002).…”

Staphylococcus aureus Bacteremia Risk in Hemodialysis Patients Using the Buttonhole Cannulation Technique: A Prospective Multicenter Study

“…Possible advantages of buttonhole cannulation, such as longer AVF patency, fewer AVF interventions, and reduced cannulation pain, have not been convincingly documented because study results are inconsistent, [5][6][7][8] and instead, increasing evidence suggests that buttonhole cannulation increases the risk for infection. [6][7][8][9][10] A few randomized controlled trials (RCTs) have been published with a limited number of patients and short follow-up 8,[11][12][13][14] ; they reported very low infection rates in both groups.…”