Advertisement
American Journal of Kidney Diseases

Arteriovenous Fistula Survival and Needling Technique: Long-term Results From a Randomized Buttonhole Trial

Published:November 18, 2013DOI:https://doi.org/10.1053/j.ajkd.2013.09.015

      Background

      We previously have shown that buttonhole needling is associated with a reduction in hematoma and postulated that buttonhole needling may increase long-term survival of an arteriovenous fistula (AVF). The purpose of this study was to evaluate AVF survival and complications in buttonhole versus standard needling.

      Study Design

      Long-term follow up of a randomized controlled trial in which participants were randomly assigned to standard or buttonhole needling and followed up until the AVF was abandoned or the study end date.

      Setting & Participants

      140 long-term hemodialysis patients in Calgary, Alberta.

      Intervention

      Buttonhole needling with median time of exposure to the intervention of 13.2 (IQR, 7.8-19.4) months.

      Outcomes & Measurements

      Patients were prospectively followed up for study outcomes. Median follow-up times were 17.2 (IQR, 11.9-37.8) and 19.2 (IQR, 12.5-41.0) months for standard and buttonhole needling, respectively (P = 0.2). The primary outcome was median access survival in months. Other outcomes included assisted and unassisted patency rates, rates of surgical and radiologic interventions, and time to abandonment (months) of buttonhole.

      Results

      Baseline characteristics were similar. The primary outcome, median access survival, was similar in both groups: 16.0 (IQR, 10.6-29.3) and 18.4 (IQR, 10.9-32.7) months for standard and buttonhole needling, respectively (P = 0.2). There were 7 (10.1%) and 6 (8.6%) thromboses with standard and buttonhole needling, respectively (P = 0.6). Median fistulogram rates were similar between techniques (P = 0.2 with intention-to-treat analysis). Most patients (46 of 70) abandoned buttonhole needling by a median of 11.3 (IQR, 4.8-18.2) months. Median time to first infection for buttonhole needling was 11.1 (IQR, 4.9-30.0) months. There were no infections in standard needling of AVFs.

      Limitations

      Findings are limited to patients needled by multiple hemodialysis nurses and not applicable to self-needlers.

      Conclusions

      AVFs with buttonhole needling did not have improved survival. The lack of survival benefit and higher risk of infection should be noted when promoting buttonhole needling.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wasse H.
        • Kutner N.
        • Zhang R.
        • Huang Y.
        Association of initial hemodialysis vascular access with patient-reported health status and quality of life.
        Clin J Am Soc Nephrol. 2007; 2: 708-714
        • Allon M.
        Current management of vascular access.
        Clin J Am Soc Nephrol. 2007; 2: 786-800
        • Polkinghorne K.R.
        • McDonald S.P.
        • Marshall M.R.
        • Atkins R.C.
        • Kerr P.G.
        Vascular access practice patterns in the New Zealand hemodialysis population.
        Am J Kidney Dis. 2004; 43: 696-704
        • Pastan S.
        • Soucie J.M.
        • McClellan W.M.
        Vascular access and increased risk of death among hemodialysis patients.
        Kidney Int. 2002; 62: 620
        • MacRae J.M.
        • Ahmed S.B.
        • Atkar R.
        • Hemmelgarn B.R.
        A randomized trial comparing buttonhole with rope ladder needling in conventional hemodialysis patients.
        Clin J Am Soc Nephrol. 2012; 7: 1632-1638
        • Lee T.
        • Barker J.
        • Allon M.
        Needle infiltration of arteriovenous fistulae in hemodialysis: risk factors and consequences.
        Am J Kidney Dis. 2006; 47: 1020-1026
        • National Kidney Foundation Vascular Access Work Group
        Clinical practice guidelines for vascular access.
        Am J Kidney Dis. 2006; 48: S176-S247
        • Jindal K.
        • Chan C.T.
        • Deziel C.
        • et al.
        Chapter 4: vascular access.
        J Am Soc Nephrol. 2006; 17: S16-S23
        • de Castro M.C.M.S.
        • de Fátima C.
        • de Souza J.M.R.
        • et al.
        Arteriovenous fistula cannulation by buttonhole technique using dull needle.
        Braz J Nephrol. 2010; 32: 281-285
        • Hsiao J.-F.
        • Chou H.-H.
        • Hsu L.-A.
        • et al.
        Vascular changes at the puncture segments of arteriovenous fistula for hemodialysis access.
        J Vasc Surg. 2010; 52: 669-673
        • Labriola L.
        • Crott R.
        • Desmet C.
        • André G.
        • Jadoul M.
        Infectious complications following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement report.
        Am J Kidney Dis. 2011; 57: 442-448
        • Nesrallah G.E.
        • Cuerden M.
        • Wong J.H.
        • Pierratos A.
        Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis.
        Clin J Am Soc Nephrol. 2010; 5: 1047-1053
        • Ball L.K.
        The buttonhole technique: strategies to reduce infections.
        Nephrol Nurs J. 2010; 37: 473-477
        • Nesrallah G.E.
        • Mustafa R.A.
        • Macrae J.
        • et al.
        Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis.
        Am J Kidney Dis. 2013; 26: 465-475
        • Vaux E.
        • King J.
        • Lloyd S.
        • et al.
        Effect of buttonhole cannulation with a polycarbonate peg on in-center hemodialysis fistula outcomes: a randomized controlled trial.
        Am J Kidney Dis. 2013; 62: 81-88