A Systematic Review of Buttonhole Cannulation Practices and Outcomes

Abstract

Buttonhole (constant site) cannulation has emerged as an attractive technique for needling arteriovenous fistulae. However, the balance of benefits and harms associated with this intervention is unclear. We conducted a systematic review of studies reporting outcomes with buttonhole cannulation. The setting and population included adult patients receiving home or center hemodialysis. We searched MEDLINE, Embase (1980-June 2012), and CINAHL (1997-June 2012), for randomized and observational studies. We also searched conference proceedings (2009-2011). The interventions included: 1) buttonhole cannulation established by sharp needles, with or without a polycarbonate peg, 2) rope-ladder cannulation. Outcomes of interest included: Facility practices, systemic infection, local infection, access survival, access interventions, access-related hospitalization, patient survival, pain, quality of life, and aneurysm formation. We identified 23 full-text articles and 4 abstracts; 3 were open-label trials, and the remainder observational studies of varying design and methodological quality. Studies were predominantly descriptive and lacked direct comparisons between buttonhole and rope-ladder cannulation. No qualitative differences in outcomes were noted among home and center hemodialysis patients using buttonhole cannulation. Rates of bacteremia were generally higher with buttonhole cannulation. Studies reporting access survival, hospitalization, quality of life, pain, and aneurysm formation had serious methodological limitations that limited our confidence in their estimates of effect. Among the various facility practices that were described, only the application of mupirocin cream was noted to be associated with reduced risk of infection. Limitations in included studies were short follow-up, crossover designs, lack of parallel control groups, and the use of patient-reported outcome measures that were not well validated. The main limitation of this review was a limited literature search. Buttonhole cannulation may be associated with an increased risk of infection. Larger, more definitive studies are needed to determine whether this technique is safe for broader use.

Infection Rates Following Buttonhole Cannulation in Hemodialysis Patients

“…Patients have reported less pain on needling and that button hole access does not lead to the aneurysmal dilatation and disfigurement that may occur with area puncture needling (Supplemental figure). However more recently a number of reports of increased infections associated with the buttonhole technique have been published , and as such meta‐analyses have concluded that the buttonhole cannulation technique is associated with higher risk of infection, but further confirmatory studies are required , as a number of studies did not report increased local infection or systemic bacteremia .…”

“…However, there have been several subsequent studies reporting a higher rate of infection associated with button hole fistula access compared with, sharp needle area puncture techniques . Recent systematic reviews have concluded that buttonhole cannulation may be associated with a higher rate of local infection and bacteremia compared with area puncture needling, but that more definitive studies are required for a firm conclusion , as some studies have not noted any increase in systemic infections from button hole needling . Infection is not the only complication of buttonhole needling, and observational studies have failed to prove a longer fistula survival time for the buttonhole technique compared to standard rope ladder needling .…”

Multi-Disciplinary Team Approach for Optimal Hemodialysis Access Care

“…The rate of local and systemic infection was higher with buttonhole than rope-ladder technique. 10,11 Nonetheless, there are vascular access or patient conditions where one technique may be preferred over the other. Clinicians must consider the pros and cons when making a decision on cannulation strategy and communicate their selection clearly to the dialysis center.…”

Venous Window Needle Guide for deep vessels and difficult arteriovenous fistula cannulation

“…However, several studies have reported medium-high risks of local and systemic infection, sometimes with serious complications, occurring at times because of the lack of appropriate disinfection protocols and preventive measures [16,17]. Although BH cannulation offers wellknown advantages such as low infiltration rate, fewer hematomas and less aneurysm formation [18], it still remains of difficult access in the presence of deep vessels, and non-feasible in specific anatomic sites (i.e., arterialized upper arm basilic vein). Only two reports have been published on VWING use.…”