The buttonhole technique for fistula cannulation: pros and cons

Abstract

Purpose of review: There has been increased interest in buttonhole cannulation, particularly in the last 5 years, because of the perceived benefit of improved fistula outcomes. The recent randomized trials provide for a timely review regarding the potential benefit and possible harms of the buttonhole technique.

Recent findings: The majority of observational studies report a reduction in pain with buttonhole; however, after reviewing the results from five randomized trials, buttonhole cannulation, when delivered by a nurse, does not appear to be less painful than rope ladder cannulation. Studies consistently report fewer infiltrations, reduced hematoma and a reduction of aneurysm formation with buttonhole. These benefits must be balanced against the increased risk of infection and septic complications seen with buttonhole cannulation.

Summary: On the basis of the current studies, buttonhole, when done in an in-center environment with many rotating staff nurses, is a complex and challenging technique. Buttonhole technique might be best utilized for difficult or limited fistula needling sites. An infection prevention education campaign along with regular audits regarding localized infections and bacteremias should be a critical part of any program which uses buttonhole cannulation. A randomized trial comparing buttonhole to rope ladder needling among home hemodialysis or self-needled patients should be the focus for future research.