A Systematic Review of Buttonhole Cannulation Practices

and Outcomes
Alexa Grudzinski,* David Mendelssohn, Andreas Pierratos, and Gihad Nesrallah*
*Division of Nephrology, Western University, London, Canada, Department of Nephrology, Humber River
Regional Hospital, Toronto, Canada, and Division of Nephrology, University of Toronto, Toronto, Canada
ABSTRACT
Buttonhole (constant site) cannulation has emerged as an
attractive technique for needling arteriovenous stulae.
However, the balance of benets and harms associated
with this intervention is unclear. We conducted a system-
atic 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 CI-
NAHL (1997-June 2012), for randomized and observa-
tional studies. We also searched conference proceedings
(20092011). The interventions included: 1) buttonhole
cannulation established by sharp needles, with or without
a polycarbonate peg, 2) rope-ladder cannulation. Out-
comes of interest included: Facility practices, systemic
infection, local infection, access survival, access interven-
tions, access-related hospitalization, patient survival, pain,
quality of life, and aneurysm formation. We identied 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 but-
tonhole and rope-ladder cannulation. No qualitative dif-
ferences 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, hospitaliza-
tion, quality of life, pain, and aneurysm formation had
serious methodological limitations that limited our con-
dence 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 limita-
tion of this review was a limited literature search. Button-
hole cannulation may be associated with an increased
risk of infection. Larger, more denitive studies are
needed to determine whether this technique is safe for
broader use.
Background
History and Evolution of the Buttonhole
Cannulation Method
Arteriovenous (AV) stulae remain the preferred
access for hemodialysis. Although they are associ-
ated with the best patient outcomes, strategies to
improve their long-term patency as well as patient
comfort and satisfaction are desirable. Cannulation
technique is a potential target for intervention.
The conventional rotating-site (rope-ladder) cannu-
lation method remains the most widely used, and
requires sharp needle puncture at new sites along
the cannulable segments of the stula with each
use. Disadvantages with this technique include the
need for sharp needles, with associated patient dis-
comfort, as well as the technically challenging nat-
ure of the cannulation procedurea potential
barrier for self-cannulation in the setting of home
hemodialysis.
Buttonhole cannulation was rst introduced in
the 1970s, (1) but has only recently gained some
degree of traction among home and center hemodi-
alysis programs worldwide. Originally termed con-
stant site cannulation, this approach is based on
repeated needle insertion into 24 consistent cannu-
lation sites, ultimately resulting in the creation of a
scar tissue tunnel tract (2). The earliest description
of the buttonhole technique involved a challenging
cannulation scenario in a patient with extremely
limited puncture sites (3). Subsequently, the method
was used for patients with short cannulable AVF
segments, or those who experienced signicant
cannulation-related pain under the rope-ladder tech-
nique. Over time, some home dialysis programs
have adopted the method as a means by which to
facilitate self-cannulation, and some programs have
adopted the technique for in-center units as well (4).
Address correspondence to: Dr. Gihad Nesrallah, Depart-
ment of Nephrology, Humber River Hospital, 200 Church
Street, Weston, Ontario, Canada, M9N 1N8, or e-mail:
gnesrallah@hrrh.on.ca
Seminars in DialysisVol 26, No 4 (JulyAugust) 2013 pp.
465475
DOI: 10.1111/sdi.12116
2013 Wiley Periodicals, Inc.
465
UNDERSTANDING & PREVENTING INFECTIOUS
COMPLICATIONS IN DIALYSIS
Purpose and Scope of this Review
We conducted a pragmatic systematic review of
the literature describing benets, harms, and techni-
cal aspects of buttonhole cannulation. We consider
and report evidence for buttonhole cannulation in
the home and in-center settings separately, given the
differences in the procedures, including operator
(nurse versus informal caregiver or patient), dialysis
prescriptions (conventional versus longer or more
frequent), and treatment setting.
Methods
A search strategy was developed in collaboration
with a Health Information Specialist at Humber
River Hospital, Toronto, Canada. We used a
pragmatic high-specicity, low-sensitivity search
strategy with variations of the term buttonhole in
MEDLINE, Embase (1980-June 2012), and CI-
NAHL (1997-June 2012), yielding 229 citations.
Titles and abstracts were imported into Endnote X6
for Macintosh, and duplicates were removed. Eligi-
ble studies included clinical trials, and observational
studies (cohort studies and case series). We excluded
studies that contained no original or usable data
(e.g., home and center patient data combined or
vascular access outcome data combined across mul-
tiple access types), and studies that did not include
patient-important outcomes (outcomes that are of
importance to patients in choosing between thera-
pies) (5). We also hand-searched abstracts from the
American Society of Nephrology (ASN) meetings,
between 2009 and 2011. Title and abstract and full-
text screening was performed independently by a
single reviewer (AG), with subsequent verication
by a second reviewer (GN) (6). Data collection
forms (available upon request) captured characteris-
tics of study participants, interventions, and the def-
initions of outcomes in included studies. We
constructed summary tables using standard thematic
analysis techniques, and information was organized
by outcome and by treatment setting (home and
center). For standardization of reporting, all event
rates were reported as events per 1000 arteriovenous
stula days (AVF-days), which is equivalent to 1000
patient-days. When count data were reported as
events per dialysis session, we converted to AVF-
days.
Results
Search and Study Selection
After removal of duplicates and title and abstract
screening, 45 of 229 citations proceeded to full-text
screening. Studies were excluded for the following
reasons: opinion piece or review with no usable ori-
ginal data (N = 18) (723), home and in-center
patient data combined and reported in aggregate
(N = 3) (2426), and no patient-important outcomes
reported (N = 2) (27,28). Twenty-two full-text arti-
cles were therefore included in this review (24,29
47). We also identied four ASN conference
abstracts published between 2009 and 2011 (4851).
Two full-text articles were separate reports of the
same study (52,53); one abstract corresponded to a
full-text publication (36,50). We identied one addi-
tional clinical trial published in 2012, after the
initial search was complete, and included it post hoc
(54).
Characteristics of Included Studies
Study characteristics are summarized in Table 1.
Included studies described in-center (N = 15), home
(N = 8), and both home and in-center patient popu-
lations (N = 4). Study designs included cohort stud-
ies with parallel control groups (N = 8), case series
(N = 12), crossover studies (N = 4), one cross-sec-
tional study, and two open-label randomized trials
(references in Table 1). Studies were small with
median sample size N = 29 (range: 2197). Included
studies were generally descriptive in nature, and
although many studies reported patient characteris-
tics, none adjusted statistically for case-mix differ-
ences. One study used multivariable regression, but
analyzed patients with grafts and stulae in aggre-
gate, and it was not possible to separate patients
with buttonhole cannulation from the remainder of
the cohort (47). Another study included patients
using both rope-ladder and buttonhole cannulation,
but did not specify event rates by cannulation
method (34,35).
Technical Aspects of the Buttonhole
Cannulation Technique
All studies that provided detailed descriptions of
their cannulation technique used a method similar
to that rst described by Twardowski et al. (1), in
which buttonholes are rst established by repeated
cannulation with sharp needles until brotic tracts
form. This usually takes place over 6 to 12 cannula-
tions, following which blunt (e.g., 15 gauge) needles
can be used (12,17). Two of 22 (10%) of studies
described using an in-dwelling polycarbonate peg
(BioHole Peg

) to guide sharp needle insertion

(39,45). Seven reports specied that a single expert
cannulator (or small number of expert cannulators)
performed all punctures during the buttonhole
establishment stages (4,33,36,38,42,44,46), and four
others reported that an expert, or at least consistent,
cannulator performed all subsequent cannulations
once buttonhole sites were established (34,37,43,47).
Site cleansing and disinfection techniques
included various combinations of soap and water,
chlorhexidine, iodine-based, and alcohol-based anti-
septic solutions. Saline, ethanol, and iodine-soaked
gauze were used to soften buttonhole scabs prior to
removal with sharp sterile needles or forceps. At
least one report described additional cleansing of
the buttonhole site with chlorhexidine solution
466 Grudzinski et al.
T
A
B
L
E
1
.
C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
o
f
i
n
c
l
u
d
e
d
s
t
u
d
i
e
s
F
i
r
s
t
a
u
t
h
o
r
a
n
d
Y
e
a
r
C
o
u
n
t
r
y
(
n
u
m
b
e
r
o
f
c
e
n
t
e
r
s
)
I
n
c
l
u
s
i
o
n
c
r
i
t
e
r
i
a
S
t
u
d
y
d
e
s
i
g
n
T
y
p
e
o
f
H
D
r
e
g
i
m
e
n
I
n
t
e
r
v
e
n
t
i
o
n
a
n
d
n
u
m
b
e
r
o
f
p
a
r
t
i
c
i
p
a
n
t
s
C
E
N
T
E
R
H
E
M
O
D
I
A
L
Y
S
I
S
B
a
c
k
e
n
r
o
t
h
2
0
1
0
a
I
s
r
a
e
l
(
1
)
C
H
D
w
i
t
h
A
V
F
P
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
C
H
D
B
H
C
(
N
=
2
3
)
R
L
C
(
N
=
2
1
)
C
a
s
t
r
o
2
0
1
0
B
r
a
z
i
l
(
1
)
C
H
D
w
i
t
h
A
V
F
P
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
H
D
B
H
C
(
N
=
1
6
)
F
i
g
u
e
i
r
e
d
o
2
0
0
8
B
r
a
z
i
l
(
1
)
C
H
D
p
a
t
i
e
n
t
s
w
i
t
h
H
D
>
3
m
o
n
t
h
s
,
>
1
8
y
e
a
r
s
,
a
n
d
w
i
t
h
a
n
a
t
i
v
e
A
V
F
i
n
u
s
e
f
o
r
a
t
l
e
a
s
t
1
m
o
n
t
h
P
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
C
H
D
B
H
C
(
N
=
1
9
)
R
L
C
(
N
=
2
8
)
G
a
l
a
n
t
e
2
0
1
0
B
r
a
z
i
l
(
1
)
C
H
D
w
i
t
h
A
V
F
R
e
t
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
H
D
B
H
C
(
N
=
1
6
)
H
a
s
h
m
i
2
0
1
0
U
n
i
t
e
d
S
t
a
t
e
s
(
3
)
P
r
e
v
a
l
e
n
t
C
H
D
p
a
t
i
e
n
t
s
p
r
e
v
i
o
u
s
l
y
r
e
c
e
i
v
i
n
g
r
o
p
e
-
l
a
d
d
e
r
c
a
n
n
u
l
a
t
i
o
n
,
a
n
d
c
o
n
v
e
r
t
e
d
t
o
B
H
C
C
r
o
s
s
-
s
e
c
t
i
o
n
a
l
C
H
D
B
H
C
(
N
=
2
6
)
L
a
b
r
i
o
l
a
2
0
1
1
B
e
l
g
i
u
m
(
1
)
A
l
l
c
e
n
t
e
r
H
D
p
a
t
i
e
n
t
s
w
i
t
h
A
V
F
R
e
t
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
H
D
(
N
=
1
7
3
)
D
a
i
l
y
H
D
(
N
=
2
)
T
w
i
c
e
w
e
e
k
l
y
H
D
(
N
=
2
)
B
H
C
(
N
=
1
7
7
)
L
u
d
l
o
w
2
0
1
0
C
a
n
a
d
a
(
1
)
A
g
e
>
1
9
y
e
a
r
s
,
E
n
g
l
i
s
h
-
s
p
e
a
k
i
n
g
,
a
n
d
a
n
H
D
o
u
t
p
a
t
i
e
n
t
w
i
t
h
a
f
u
n
c
t
i
o
n
i
n
g
A
V
F
P
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
P
r
e
s
u
m
e
d
C
H
D
(
N
=
1
6
)
B
H
C
(
N
=
1
6
)
M
a
c
R
a
e
2
0
1
2
C
a
n
a
d
a
(
1
)
A
g
e
>
1
8
y
e
a
r
s
,
w
i
t
h
a
s
t
a
b
l
e
A
V
F
w
i
t
h
a
n
a
c
c
e
s
s

o
w
>
5
0
0
m
l
/
m
i
n
.
P
a
t
i
e
n
t
s
w
i
t
h
p
l
a
n
n
e
d
m
o
v
e
o
r
t
r
a
n
s
p
l
a
n
t
,
o
r
t
h
o
s
e
u
s
i
n
g
t
o
p
i
c
a
l
a
n
e
s
t
h
e
t
i
c
s
o
r
s
e
l
f
-
c
a
n
n
u
l
a
t
i
n
g
w
e
r
e
e
x
c
l
u
d
e
d
O
p
e
n
-
l
a
b
e
l
r
a
n
d
o
m
i
z
e
d
t
r
i
a
l
C
H
D
(
N
=
1
4
0
)
B
H
C
(
N
=
7
0
)
M
a
r
t
i
c
o
r
e
n
a
2
0
0
6
C
a
n
a
d
a
(
1
)
C
H
D
a
n
d
D
a
i
l
y
H
D
p
a
t
i
e
n
t
s
w
i
t
h
c
a
n
n
u
l
a
t
i
o
n
p
r
o
b
l
e
m
s
o
n
R
L
C
,
i
n
c
l
u
d
i
n
g
p
r
o
l
o
n
g
e
d
b
l
e
e
d
i
n
g
n
o
t
d
u
e
t
o
c
e
n
t
r
a
l
o
r
r
e
g
i
o
n
a
l
s
t
e
n
o
s
i
s
(
N
=
6
)
P
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
H
D
(
N
=
9
)
D
a
i
l
y
H
D
(
N
=
5
)
B
H
C
(
N
=
1
4
)
P
e
r
g
o
l
o
t
t
i
2
0
1
1
U
n
i
t
e
d
S
t
a
t
e
s
(
1
)
C
e
n
t
e
r
C
H
D
p
a
t
i
e
n
t
s
w
i
t
h
a
g
e
>
1
8
y
e
a
r
s
,
o
n
H
D
>
6
m
o
n
t
h
s
,
a
n
d
n
a
t
i
v
e
A
V
F
u
s
i
n
g
B
H
C
>
2
m
o
n
t
h
s
R
e
t
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
s
t
u
d
y
P
r
e
s
u
m
e
d
C
H
D
(
N
=
6
6
)
B
H
C
(
N
=
4
5
)

T
r
a
d
i
t
i
o
n
a
l
C
a
n
n
u
l
a
t
i
o
n

P
r
e
s
u
m
e
d
R
L
C
(
N
=
2
1
)
Q
u
i
n
a
n
2
0
0
8
C
a
n
a
d
a
(
1
)
C
e
n
t
e
r
C
H
D
p
a
t
i
e
n
t
s
w
i
t
h
a
g
e
>
1
9
y
e
a
r
s
,
E
n
g
l
i
s
h
-
s
p
e
a
k
i
n
g
,
f
u
n
c
t
i
o
n
i
n
g
A
V
F
P
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
H
D
(
N
=
2
9
)
B
H
C
(
N
=
2
9
)
S
i
l
v
a
2
0
1
0
B
r
a
z
i
l
(
1
)
S
h
o
r
t
c
a
n
n
u
l
a
b
l
e
s
e
g
m
e
n
t
s
(
N
=
9
)
,
d
i
f

c
u
l
t
c
a
n
n
u
l
a
t
i
o
n
w
i
t
h
r
e
c
u
r
r
e
n
t
h
e
m
a
t
o
m
a
f
o
r
m
a
t
i
o
n
(
N
=
8
)
,
s
e
v
e
r
e
c
a
n
n
u
l
a
t
i
o
n
-
r
e
l
a
t
e
d
p
a
i
n
(
N
=
4
)
P
a
t
i
e
n
t
s
w
e
r
e
i
n
e
l
i
g
i
b
l
e
i
f
t
h
e
y
h
a
d
a
g
r
a
f
t
,
A
V
F
s
t
e
n
o
s
i
s
,
p
o
o
r
p
e
r
s
o
n
a
l
h
y
g
i
e
n
e
,
l
o
c
a
l
i
n
f
e
c
t
i
o
n
,
o
r
p
o
o
r
s
k
i
n
i
n
t
e
g
r
i
t
y
P
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
D
a
i
l
y
H
D
(
N
=
2
1
)
B
H
C
(
N
=
2
1
)
T
o
m
a
2
0
0
3
J
a
p
a
n
(
1
)
C
H
D
w
i
t
h
A
V
F
O
p
e
n
-
l
a
b
e
l
r
a
n
d
o
m
i
z
e
d
t
r
i
a
l
C
H
D
B
H
C
w
i
t
h
B
i
o
h
o
l
e
P
e
g

(
N
=
4
3
)
R
L
C
(
N
=
4
3
)
BUTTONHOLE CANNULATION REVIEW 467
T
a
b
l
e
1
.
(
C
o
n
t
i
n
u
e
d
)
F
i
r
s
t
a
u
t
h
o
r
a
n
d
Y
e
a
r
C
o
u
n
t
r
y
(
n
u
m
b
e
r
o
f
c
e
n
t
e
r
s
)
I
n
c
l
u
s
i
o
n
c
r
i
t
e
r
i
a
S
t
u
d
y
d
e
s
i
g
n
T
y
p
e
o
f
H
D
r
e
g
i
m
e
n
I
n
t
e
r
v
e
n
t
i
o
n
a
n
d
n
u
m
b
e
r
o
f
p
a
r
t
i
c
i
p
a
n
t
s
v
a
n
L
o
o
n
2
0
1
0
B
e
l
g
i
u
m
a
n
d
T
h
e
N
e
t
h
e
r
l
a
n
d
s
(
3
)
W
e
l
l
-
f
u
n
c
t
i
o
n
i
n
g
A
V
F
w
i
t
h
a
c
c
e
s
s

o
w
o
f

5
0
0
m
l
/
m
i
n
,
d
i
a
m
e
t
e
r
o
f

6
m
m
,
a
n
d
a
b
l
e
t
o
c
a
n
n
u
l
a
t
e
w
i
t
h
t
w
o
n
e
e
d
l
e
s
.
O
n
e
c
e
n
t
e
r
e
x
c
l
u
s
i
v
e
l
y
u
s
e
d
B
H
C
;
t
w
o
c
e
n
t
e
r
s
i
n
c
l
u
d
e
d
p
r
e
v
a
l
e
n
t
p
a
t
i
e
n
t
s
u
s
i
n
g
R
L
C
o
n
l
y
P
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
s
t
u
d
y
C
H
D
B
H
C
(
N
=
7
5
)
R
L
C
(
N
=
7
0
)
W
a
r
d
2
0
1
0
U
n
i
t
e
d
K
i
n
g
d
o
m
(
1
)
A
l
l
p
a
t
i
e
n
t
s
w
h
o
w
e
r
e
u
s
i
n
g
R
L
C
a
t
a
s
a
t
e
l
l
i
t
e
c
e
n
t
e
r
s
w
i
t
c
h
e
d
t
o
B
H
C
;
a
l
l
n
e
w
H
D
p
a
t
i
e
n
t
s
s
t
a
r
t
e
d
o
n
B
H
C
P
r
o
s
p
e
c
t
i
v
e
c
r
o
s
s
o
v
e
r
s
t
u
d
y
C
H
D
B
H
C
(
N
=
5
3
)
H
O
M
E
A
N
D
C
E
N
T
E
R
H
E
M
O
D
I
A
L
Y
S
I
S
D
o
s
s
2
0
0
8
U
n
i
t
e
d
S
t
a
t
e
s
(
1
)
C
e
n
t
e
r
a
n
d
h
o
m
e
H
D
u
s
i
n
g
B
H
C
P
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
s
t
u
d
y
C
e
n
t
e
r
H
D
(
N
=
1
3
7
)
H
o
m
e
H
D
(
N
=
6
0
)
B
H
C
i
n
c
e
n
t
e
r
(
N
=
1
3
7
)
B
H
C
a
t
h
o
m
e
(
N
=
6
0
)
G
r
a
y
2
0
1
0
A
u
s
t
r
a
l
i
a
C
e
n
t
e
r
a
n
d
h
o
m
e
H
D
u
s
i
n
g
B
H
C
R
e
t
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
e
n
t
e
r
H
D
(
N
=
1
)
H
o
m
e
H
D
(
N
=
1
)
B
H
C
(
N
=
2
)
M
a
r
t
i
c
o
r
e
n
a
2
0
0
9
C
a
n
a
d
a
(
1
)
C
e
n
t
e
r
C
H
D
p
a
t
i
e
n
t
s
w
i
t
h
l
i
m
i
t
e
d
a
r
e
a
f
o
r
c
a
n
n
u
l
a
t
i
o
n
,
h
o
m
e
H
D
,
o
r
p
r
e
f
e
r
e
n
c
e
f
o
r
B
H
C
P
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
e
n
t
e
r
H
D
(
N
=
9
)
H
o
m
e
H
D
(
N
=
3
)
D
a
i
l
y
H
D
(
N
n
o
t
s
p
e
c
i

e
d
)
B
H
C
(
N
=
1
2
)
M
a
r
t
i
c
o
r
e
n
a
2
0
1
1
C
a
n
a
d
a
(
1
)
S
h
o
r
t
u
s
a
b
l
e
s
e
g
m
e
n
t
s
,
d
i
f

c
u
l
t
c
a
n
n
u
l
a
t
i
o
n
,
h
o
m
e
H
D
,
o
r
p
a
t
i
e
n
t
p
r
e
f
e
r
e
n
c
e
R
e
t
r
o
s
p
e
c
t
i
v
e
c
a
s
e
s
e
r
i
e
s
C
e
n
t
e
r
H
D
(
N
=
5
)
H
o
m
e
H
D
(
N
=
7
)
B
H
C
w
i
t
h
B
i
o
h
o
l
e
P
e
g

(
N
=
1
2
)
H
O
M
E
H
E
M
O
D
I
A
L
Y
S
I
S
L
o
k
2
0
1
1
a
C
a
n
a
d
a
(
2
)
H
o
m
e
H
D
u
s
i
n
g
B
H
C
R
e
t
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
s
t
u
d
y
H
o
m
e
N
H
D
(
N
=
1
2
8
)
H
o
m
e
D
a
i
l
y
H
D
(
N
=
4
6
)
B
H
C
(
N
=
1
7
4
)
M
u
i
r
2
0
1
1
a
A
u
s
t
r
a
l
i
a
(
1
)
H
o
m
e
H
D
u
s
i
n
g
B
H
C
R
e
t
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
s
t
u
d
y
H
o
m
e
N
H
D
a
n
d
D
a
i
l
y
H
D
(
N
=
9
0
)
B
H
C
(
N
=
9
0
)
L
e
i
t
c
h
2
0
0
3
,
L
i
n
d
s
a
y
2
0
0
3
C
a
n
a
d
a
(
1
)
H
D
o
r
P
D
p
a
t
i
e
n
t
s
>
1
8
y
e
a
r
s
,
o
n
d
i
a
l
y
s
i
s
f
o
r
>
3
m
o
n
t
h
s
,
a
n
t
i
c
i
p
a
t
e
d
s
u
r
v
i
v
a
l
>
1
y
e
a
r
P
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
s
t
u
d
y
H
o
m
e
D
a
i
l
y
H
D
(
N
=
1
1
)
H
o
m
e
N
H
D
(
N
=
1
2
)
B
H
C
(
N
=
n
o
t
s
p
e
c
i

e
d
)
N
e
s
r
a
l
l
a
h
2
0
0
9
a
,
N
e
s
r
a
l
l
a
h
2
0
1
0
C
a
n
a
d
a
(
1
)
H
o
m
e
n
o
c
t
u
r
n
a
l
H
D
p
a
t
i
e
n
t
s
w
i
t
h
A
V
F
w
i
t
h
s
e
l
f
-
c
a
n
n
u
l
a
t
i
o
n
u
s
i
n
g
B
H
C
R
e
t
r
o
s
p
e
c
t
i
v
e
c
r
o
s
s
o
v
e
r
s
t
u
d
y
H
o
m
e
N
H
D
(
N
=
5
6
)
B
H
C
(
N
=
5
6
)
v
a
n
E
p
s
,
2
0
1
0
A
u
s
t
r
a
l
i
a
(
1
)
H
o
m
e
H
D
p
a
t
i
e
n
t
s
>
1
8
y
e
a
r
s
,
o
n
h
o
m
e
H
D
>
3
m
o
n
t
h
s
,
a
n
d
c
o
n
v
e
r
t
e
d
t
o
h
o
m
e
N
H
D
,
a
n
d
u
s
i
n
g
e
i
t
h
e
r
A
V
F
w
i
t
h
B
H
C
,
o
r
A
V
G
;
c
o
n
t
r
o
l
g
r
o
u
p
i
n
c
l
u
d
e
d
c
e
n
t
e
r
H
D
p
a
t
i
e
n
t
s
u
s
i
n
g
R
L
C
R
e
t
r
o
s
p
e
c
t
i
v
e
c
o
h
o
r
t
s
t
u
d
y
H
o
m
e
N
H
D
(
N
=
6
3
)
H
o
m
e
C
H
D
(
N
=
2
0
)
C
e
n
t
e
r
C
H
D
(
N
=
1
5
2
)
B
H
C
w
i
t
h
C
H
D
(
N
=
1
5
)
R
L
C
w
i
t
h
C
H
D
(
N
=
1
5
7
)
B
H
C
w
i
t
h
N
H
D
(
N
=
5
9
)
R
L
C
w
i
t
h
N
H
D
(
N
=
4
)
V
e
r
h
a
l
l
e
n
2
0
0
7
T
h
e
N
e
t
h
e
r
l
a
n
d
s
(
3
)
H
o
m
e
H
D
p
a
t
i
e
n
t
s
w
i
t
h
a
n
a
t
o
m
i
c
a
l
p
r
o
b
l
e
m
s
(
N
=
1
5
)
o
r
b
a
d
s
t
i
c
k
s
o
r
p
a
i
n
f
u
l
c
a
n
n
u
l
a
t
i
o
n
(
N
=
1
8
)
R
e
t
r
o
s
p
e
c
t
i
v
e
c
r
o
s
s
o
v
e
r
s
t
u
d
y
H
o
m
e
,
P
r
e
s
u
m
e
d
C
H
D
(
N
=
3
3
)
B
H
C
(
N
=
3
3
)
a
C
o
n
f
e
r
e
n
c
e
a
b
s
t
r
a
c
t
s
;
a
l
l
o
t
h
e
r
r
e
p
o
r
t
s
a
r
e
f
u
l
l
-
t
e
x
t
m
a
n
u
s
c
r
i
p
t
s
.
A
V
F
,
a
r
t
e
r
i
o
v
e
n
o
u
s

s
t
u
l
a
;
B
H
C
,
b
u
t
t
o
n
h
o
l
e
c
a
n
n
u
l
a
t
i
o
n
;
C
H
D
,
c
o
n
v
e
n
t
i
o
n
a
l
(
t
h
r
e
e
t
i
m
e
s
p
e
r
w
e
e
k
)
h
e
m
o
d
i
a
l
y
s
i
s
;
N
H
D
,
n
o
c
t
u
r
n
a
l
h
e
m
o
d
i
a
l
y
s
i
s
;
R
L
C
,
r
o
p
e
-
l
a
d
d
e
r
c
a
n
n
u
l
a
t
i
o
n
.
468 Grudzinski et al.
following successful scab removal (45). Two reports
described applying topical antimicrobial cream or
ointment to buttonhole sites after needle removal
and hemostasis (36,45).
Systemic Infection
Home Hemodialysis
Bacteremia rates among home dialysis popula-
tions ranged between 0.00 and 0.28 per 1000 AVF-
days across 6 studies, which included 416 patients,
followed for 1069 patient-years (3,36,41,43,4850).
Three studies specically examined the absolute
risk of Staphylococcus aureus (S. aureus) bactere-
mia for patients who received home (frequent or
long) hemodialysis using buttonhole cannulation,
and reported between 0.15 and 0.28 episodes per
1000 patient-days (Table 2) (36,48,49). At least one
study reported metastatic complications, including
septic arthritis, septic pulmonary emboli, vertebral
osteomyelitis, and death (36). Two studies reported
no infections during follow-up (41,43), although
one had extremely short follow-up (Table 2) (43).
In a report from our center, we described the rates
of bacteremia with and without topical antimicro-
bial prophylaxis (with mupirocin cream) at the
cannulation site in 56 patients using the buttonhole
cannulation technique for home nocturnal hemo-
dialysis. The odds ratio for bacteremia in the
absence of mupirocin cream was 6.4 (95%
CI = 1.332.3), although the study was limited by
a prepost design. One study by Marticorena et al.
included both home-treated and center-treated
patients using the BioHole device, and reported no
bacteremic episodes during 168 AVF-days in 12
patients (45).
In-center Hemodialysis
Reported bacteremia rates for in-center popula-
tions (Table 2) ranged between 0.00 and 0.31 per
1000 AVF-days, with a total of 87 events in 543
patients followed for 1034 patient-years. van Loon
et al. reported two cases of S. aureus bacteremia,
and one case with an unspecied gram-positive
organism in a cohort of 75 patients using button-
hole cannulation for an average of 9 months. (40)
Labriola et al. reported a baseline bacteremia rate
of 0.17 events/1000 AVF-days with rope-ladder
cannulation, which rose to 0.43 events/1000 AVF-
days after a 2-year transition period, during which
all patients with AVF converted to buttonhole
cannulation. Following a nursing staff education
session, infection rates fell slightly to 0.34 events/
1000 AVF-days, suggesting a training effect and
operator dependency (4). Silva et al., reported an
episode of bacteremia with coagulase-negative
staphylococci, complicated by a paravertebral
abscess, which resolved with treatment (2). In the
clinical trial by MacRae et al., a single episode of
S. aureus bacteremia was observed during the
8-week study period, with an additional 2 episodes
of bacteremia within 12 months of study initiation
in 9 patients who continued to receive buttonhole
cannulation (54).
Facility Practices and Systemic Infection Rates
Selected facility practices and corresponding sys-
temic infection rates are reported in Table 2. The
small number of studies and available data pre-
cluded any statistical evaluation of relationships
between practices and infection rates. Qualitatively,
it did not appear that dialysis frequency, the use of
a single expert cannulator, treatment setting (home
versus center), or cleansing protocol were associated
with bacteremia rates. However, a decrease in bac-
teremia rates was attributed to staff education and
reinforcement of proper practices in at least one
study (4). It is noteworthy that two studies that
reported using topical antimicrobial cream observed
no infections (36,43). It is also noteworthy that two
studies in which a polycarbonate peg was used to
establish buttonhole sites observed no systemic
infections during follow-up (39,45); however, fol-
low-up times were limited (2 weeks3 months per
patient).
Local Infections
Home Hemodialysis
Local infection rates ranged between 0.00 and
0.18 events/1000 AVF-days across 5 studies, report-
ing a total of 26 infections in 413 patients over 1079
patient-years of follow-up (3,36,41,48,55). A study
by Leitch et al. reported an overall infection rate of
0.04 events/1000 AVF-days in 23 patients followed
for up to 18 months. However, the proportion of
patients using buttonhole cannulation was not spec-
ied (34). Our facility reported three local infections
(0.03 events/1000 patient-days) prior to introducing
topical mupirocin prophylaxis, and no local infec-
tions thereafter (56).
In-center Hemodialysis
Five studies reported local infection data, with
rates ranging between 0.13 and 1.93 events/1000
patient-days with 18 infections occurring in 292 in-
center patients over 238 patient-years of follow-up
(2,3,39,40,46). In the clinical trial by MacRae et al.,
the rates of local infection were 9.6 versus 21.4 epi-
sodes per 1000 AVF-days with rope-ladder versus
buttonhole cannulation, respectively (p < 0.003).
After the 8-week study period, 9 additional local
infections with abscess formation were observed,
and required treatment with intravenous antibiotics
(54). One study, in which polycarbonate pegs were
used to establish cannulation tunnel tracts, reported
a single suspected local infection in 80 patients
followed for 7200 AVF-days (0.14 events/1000
AVF-days) (39).
BUTTONHOLE CANNULATION REVIEW 469
T
A
B
L
E
2
.
R
a
t
e
s
o
f
b
a
c
t
e
r
e
m
i
a
a
n
d
f
a
c
i
l
i
t
y
p
r
a
c
t
i
c
e
s
F
i
r
s
t
A
u
t
h
o
r
/
Y
e
a
r
N
a
t
r
i
s
k
T
i
m
e
a
t
r
i
s
k
(
p
t
-
d
a
y
s
)
C
o
u
n
t
o
f
b
a
c
t
e
r
e
m
i
a
e
p
i
s
o
d
e
s
E
v
e
n
t
r
a
t
e
(
b
a
c
t
e
r
e
m
i
a
/
1
0
0
0
A
V
F
-
d
a
y
s
)
H
D
p
e
r
w
e
e
k
P
r
i
m
a
r
y
c
a
n
n
u
l
a
t
o
r
w
h
i
l
e
e
s
t
a
b
l
i
s
h
i
n
g
t
r
a
c
t
s
P
r
i
m
a
r
y
c
a
n
n
u
l
a
t
o
r
a
f
t
e
r
t
r
a
c
t
s
e
s
t
a
b
l
i
s
h
e
d
S
i
t
e
c
a
r
e
p
r
o
t
o
c
o
l
C
E
N
T
E
R
H
E
M
O
D
I
A
L
Y
S
I
S
B
a
c
k
e
n
r
o
t
h
2
0
1
0
a
2
3
5
1
5
4
0
1
4
0
.
2
7
3
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
D
o
s
s
2
0
0
8
1
3
7
6
2
6
5
2
1
0
0
.
1
6
3
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
S
o
a
p
,
a
l
c
o
h
o
l
w
i
p
e
s
,
c
h
l
o
r
h
e
x
i
d
i
n
e
L
a
b
r
i
o
l
a
2
0
1
1
1
7
7
1
8
6
4
8
1
3
3
0
.
4
3
b
3
(
N
=
1
7
3
)
6
(
N
=
2
)
2
(
N
=
2
)
S
i
n
g
l
e
e
x
p
e
r
t
R
N
B
H
c
a
n
n
u
l
a
t
o
r
A
n
y
R
N
w
i
t
h
B
H
C
t
r
a
i
n
i
n
g
S
o
a
p
a
n
d
w
a
t
e
r
,
a
l
c
o
h
o
l
i
c
p
o
v
i
d
o
n
e
i
o
d
i
n
e
M
a
c
R
a
e
2
0
1
2
7
0
N
R
3

3
S
i
n
g
l
e
e
x
p
e
r
t
R
N
c
a
n
n
u
l
a
t
o
r
A
n
y
R
N
w
i
t
h
B
H
C
t
r
a
i
n
i
n
g
C
h
l
o
r
h
e
x
i
d
i
n
e
/
7
0
%
a
l
c
o
h
o
l
M
a
r
t
i
c
o
r
e
n
a
2
0
0
6
1
4
5
1
1
0
1
0
.
2
0
3

6
O
n
e
o
f
t
w
o
e
x
p
e
r
t
c
a
n
n
u
l
a
t
o
r
s
O
n
e
o
f

v
e
e
x
p
e
r
t
c
a
n
n
u
l
a
t
o
r
s
C
h
l
o
r
h
e
x
i
d
i
n
e
o
r
p
o
v
i
d
o
n
e
-
i
o
d
i
n
e
s
o
l
u
t
i
o
n
M
a
r
t
i
c
o
r
e
n
a
2
0
0
9
9
1
2
6
0
0
.
0
0
3

6
A
n
y
e
x
p
e
r
t
R
N
B
H
c
a
n
n
u
l
a
t
o
r
S
e
l
f
-
c
a
n
n
u
l
a
t
i
o
n
w
i
t
h
o
r
w
i
t
h
o
u
t
a
s
s
i
s
t
a
n
c
e
f
r
o
m
a
n
y
R
N
P
o
v
i
d
o
n
e
-
i
o
d
i
n
e
s
o
l
u
t
i
o
n
;
t
o
p
i
c
a
l
a
n
t
i
m
i
c
r
o
b
i
a
l
p
r
o
p
h
y
l
a
x
i
s
w
i
t
h
P
o
l
y
s
p
o
r
i
n

(
P

z
e
r
C
a
n
a
d
a
I
n
c
.
,
M
a
r
k
h
a
m
,
O
N
,
C
a
n
a
d
a
)
S
i
l
v
a
2
0
1
0
2
1
7
6
6
5
2
0
.
2
6
6
S
i
n
g
l
e
e
x
p
e
r
t
R
N
c
a
n
n
u
l
a
t
o
r
;
u
n
c
l
e
a
r
i
f
e
x
p
e
r
t
i
s
e
i
n
B
H
c
a
n
n
u
l
a
t
i
o
n
N
u
r
s
e
a
s
s
i
s
t
a
n
t
s
S
a
l
i
n
e
g
a
u
z
e
,
e
t
h
y
l
a
l
c
o
h
o
l
T
o
m
a
2
0
0
3
4
3
3
8
7
0
0
0
.
0
0
3
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
v
a
n
L
o
o
n
2
0
1
0
7
5
4
1
5
8
0
3
0
.
0
7
3
O
n
e
o
f
t
h
r
e
e
e
x
p
e
r
t
R
N
c
a
n
n
u
l
a
t
o
r
s
A
n
y
R
N
w
i
t
h
B
H
C
t
r
a
i
n
i
n
g
C
h
l
o
r
h
e
x
i
d
i
n
e
W
a
r
d
2
0
1
0
4
4
1
8
4
8
0
0
0
.
0
0
3
S
i
n
g
l
e
e
x
p
e
r
t
R
N
B
H
c
a
n
n
u
l
a
t
o
r
A
n
y
R
N
w
i
t
h
B
H
C
t
r
a
i
n
i
n
g
S
o
a
p
,
a
l
c
o
h
o
l
w
i
p
e
s
,
c
h
l
o
r
h
e
x
i
d
i
n
e
H
O
M
E
H
E
M
O
D
I
A
L
Y
S
I
S
D
o
s
s
2
0
0
8
6
0
3
2
0
8
8
6
0
.
1
9
3
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
,
p
r
e
s
u
m
e
d
s
e
l
f
-
c
a
n
n
u
l
a
t
i
o
n
S
o
a
p
,
a
l
c
o
h
o
l
w
i
p
e
s
,
c
h
l
o
r
h
e
x
i
d
i
n
e
L
o
k
2
0
1
1
a
1
7
4
1
9
8
9
1
0
3
6
0
.
1
8
3

6
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
,
p
r
e
s
u
m
e
d
s
e
l
f
-
c
a
n
n
u
l
a
t
i
o
n
N
o
t
s
p
e
c
i

e
d
M
a
r
t
i
c
o
r
e
n
a
2
0
0
9
3
4
2
0
0
.
0
0
N
o
t
s
p
e
c
i

e
d
A
n
y
e
x
p
e
r
t
R
N
B
H
c
a
n
n
u
l
a
t
o
r
S
e
l
f
-
c
a
n
n
u
l
a
t
i
o
n
w
i
t
h
o
r
w
i
t
h
o
u
t
a
s
s
i
s
t
a
n
c
e
f
r
o
m
a
n
y
R
N
P
o
v
i
d
o
n
e
-
i
o
d
i
n
e
s
o
l
u
t
i
o
n
;
t
o
p
i
c
a
l
a
n
t
i
m
i
c
r
o
b
i
a
l
p
r
o
p
h
y
l
a
x
i
s
w
i
t
h
P
o
l
y
s
p
o
r
i
n

(
P

z
e
r
C
a
n
a
d
a
I
n
c
.
,
M
a
r
k
h
a
m
,
O
N
,
C
a
n
a
d
a
)
470 Grudzinski et al.
Access Survival
Home Hemodialysis
During 289 patient-years of follow-up, our facility
documented no episodes of permanent access loss in
a cohort of home nocturnal dialysis patients using
buttonhole cannulation (56). Leitch and Lindsay
reported 5 permanent access failures in over 22.5
AVF-years in 15 patients, but it was not clear how
many of these were among buttonhole cannulation
users (34,35). Verhallen et al. reported a single per-
manent access loss among 33 home hemodialysis
patients followed for 363 patient-months (41).
No studies reported access survival in in-center
populations.
Access Interventions
In a home hemodialysis cohort, Muir et al. found
no difference in the surgical intervention rates for
buttonhole versus rope-ladder cannulation users
(incident rate ratio = 1.08; 95% CI = 0.333.55;
p = 0.90) (49). Ward et al. reported that 24% of
patients in their cohort required an endovascular
procedure prior to converting to buttonhole cannu-
lation, but after a median of 14 months (range: 9.5
22.5 months), only three procedures were performed
(v
2
= 5.6, p = 0.008) (11). In the study by van Loon,
endovascular interventions occurred at a rate of 0.2
versus 0.8 per patient year in patients using button-
hole as compared with parallel control subjects
using rope-ladder cannulation, respectively
(p < 0.001) (40).
Access-Related Hospitalizations
An abstract by Lok et al. reported 5 hospitaliza-
tions in a cohort of 174 home hemodialysis patients
using buttonhole cannulation and followed for
198,910 AVF-days (hospitalization rate = 0.03 per
1000 AVF-days) (48).
Mortality
In general, studies had small populations and were
heterogeneous in design. This precluded any mean-
ingful interpretation of deaths related to buttonhole
cannulation. One study reported a case of vertebral
osteomyelitis attributed to buttonhole cannulation
this was further complicated by quadriplegia and
resulted in withdrawal from dialysis (36).
Pain and Quality of Life Measures
Studies reported a range of quality of life, pain,
and related measures, primarily consisting of visual
analog scales with no documentation of instrument
validation or measurement properties. Evidence of
oor effects (clustering of scores within a low and
narrow range) was present with mean scores of less
than 3 on a 10-point scale (with both buttonhole
T
a
b
l
e
2
.
(
C
o
n
t
i
n
u
e
d
)
F
i
r
s
t
A
u
t
h
o
r
/
Y
e
a
r
N
a
t
r
i
s
k
T
i
m
e
a
t
r
i
s
k
(
p
t
-
d
a
y
s
)
C
o
u
n
t
o
f
b
a
c
t
e
r
e
m
i
a
e
p
i
s
o
d
e
s
E
v
e
n
t
r
a
t
e
(
b
a
c
t
e
r
e
m
i
a
/
1
0
0
0
A
V
F
-
d
a
y
s
)
H
D
p
e
r
w
e
e
k
P
r
i
m
a
r
y
c
a
n
n
u
l
a
t
o
r
w
h
i
l
e
e
s
t
a
b
l
i
s
h
i
n
g
t
r
a
c
t
s
P
r
i
m
a
r
y
c
a
n
n
u
l
a
t
o
r
a
f
t
e
r
t
r
a
c
t
s
e
s
t
a
b
l
i
s
h
e
d
S
i
t
e
c
a
r
e
p
r
o
t
o
c
o
l
M
u
i
r
2
0
1
1
a
9
0
1
1
2
9
5
0
1
7
0
.
1
5
3

6
N
o
t
s
p
e
c
i

e
d
N
o
t
s
p
e
c
i

e
d
,
p
r
e
s
u
m
e
d
s
e
l
f
-
c
a
n
n
u
l
a
t
i
o
n
N
o
t
s
p
e
c
i

e
d
N
e
s
r
a
l
l
a
h
2
0
0
9
a
,
N
e
s
r
a
l
l
a
h
2
0
1
0
5
6
3
5
3
1
6
1
0
0
.
2
8
c
3

7
S
i
n
g
l
e
e
x
p
e
r
t
R
N
B
H
c
a
n
n
u
l
a
t
o
r
S
i
n
g
l
e
e
x
p
e
r
t
R
N
c
a
n
n
u
l
a
t
o
r
o
r
s
e
l
f
-
c
a
n
n
u
l
a
t
i
o
n
C
h
l
o
r
h
e
x
i
d
i
n
e
o
r
p
o
v
i
d
o
n
e
-
i
o
d
i
n
e
s
o
l
u
t
i
o
n
,
a
n
d
a
l
c
o
h
o
l
p
a
d
s
;
t
o
p
i
c
a
l
m
u
p
i
r
o
c
i
n
p
r
o
p
h
y
l
a
x
i
s
V
e
r
h
a
l
l
e
n
2
0
0
7
3
3
1
0
8
9
0
0
0
.
0
0
N
o
t
s
p
e
c
i

e
d
S
e
l
f
S
e
l
f
E
t
h
a
n
o
l
a
C
o
n
f
e
r
e
n
c
e
a
b
s
t
r
a
c
t
s
;
a
l
l
o
t
h
e
r
r
e
p
o
r
t
s
a
r
e
f
u
l
l
-
t
e
x
t
m
a
n
u
s
c
r
i
p
t
s
.
b
B
a
c
t
e
r
e
m
i
a
r
a
t
e
r
e
p
o
r
t
e
d
b
y
a
u
t
h
o
r
s
d
u
r
i
n
g
t
h
e
h
i
g
h
e
s
t
r
i
s
k
p
e
r
i
o
d
o
f
o
b
s
e
r
v
a
t
i
o
n
,
b
e
f
o
r
e
a
n
u
r
s
e
e
d
u
c
a
t
i
o
n
a
l
i
n
t
e
r
v
e
n
t
i
o
n
.
c
I
n
f
e
c
t
i
o
n
r
a
t
e
p
r
i
o
r
t
o
t
h
e
i
n
t
r
o
d
u
c
t
i
o
n
o
f
t
o
p
i
c
a
l
m
u
p
i
r
o
c
i
n
p
r
o
p
h
y
l
a
x
i
s
.
B
H
,
b
u
t
t
o
n
h
o
l
e
;
N
R
,
n
o
t
r
e
p
o
r
t
e
d
;
R
N
,
r
e
g
i
s
t
e
r
e
d
n
u
r
s
e
.
BUTTONHOLE CANNULATION REVIEW 471
and rope-ladder cannulation) in some studies
(29,33,38,40,54). Nevertheless, most observational
studies suggested less pain after converting to but-
tonhole cannulation (2,29,32,33,3739,42,44), while
only one suggested no difference (41). In the study
by van Loon, patients using rope-ladder cannula-
tion had less pain, but a greater proportion of these
patients used topical anesthetic cream (40). In the
clinical trial by MacRae et al., the difference in pain
scores after 8 weeks of buttonhole versus rope-lad-
der cannulation was not signicant (54). Patients in
this trial did not self-cannulate.
Aneurysm Formation
Ward and Verhallen reported no new aneurysm
formation in their study cohorts (41,42). Van Loon
reported a 67% versus 1% incidence of aneurysm
formation in rope-ladder versus buttonhole cannula-
tion patients (40). Similarly, 12% versus 24% of
patients using buttonhole versus rope-ladder cannu-
lation had aneurysms in the study by Hashmi (32).
Finally, Pergolotti et al. noted aneurysms in 46% of
patients using the traditional cannulation method
compared to 20% in buttonhole cannulation users.
In all of these studies, it was unclear as to whether
patients had aneurysms prior to entering study fol-
low-up, the measurement and denition of aneurys-
mal dilatation were not clear, and prior access
history (including stula vintage) was not reported
(37). Marticorena et al. documented regression of
aneurysmal dilatation in two patients over 1 year
follow-up (44). None of the other 20 included stud-
ies reported anatomical outcomes.
Discussion
Arteriovenous stulae remain the access of choice
for patients undergoing hemodialysis. Although
they are associated with the best patient outcomes,
needle aversion, pain, and technical complexity are
important patient-level barriers to stulae use, espe-
cially in the home setting. These factors may con-
tribute to a lower incident rate of stula use among
patients initiating hemodialysis. Potentially modi-
able factors such as stenosis and progressive
aneurysmal dilatation are important causes of per-
manent access abandonment, and a lower prevalent
rate of stula use. Although it is by far the most
widely used method for cannulation, the rope-ladder
method may contribute to many of these complica-
tions. The buttonhole cannulation method has been
promoted as a promising alternative, with numerous
enthusiastic anecdotal reports suggesting less cannu-
lation pain, needle aversion, and aneurysm forma-
tion; moreover, it lends itself well to self-
cannulation, which is particularly relevant for home
dialysis delivery. At the same time, a growing body
of evidence suggests an increased risk of infection
with this technique that must be taken seriously and
balanced against any potential benets.
Summary of Findings and Study Quality
Appraisal
In this review, we summarize the current litera-
ture describing populations and outcomes associ-
ated with buttonhole cannulation, and attempt to
weigh the relative benets and harms associated
with this intervention. Most included reports were
of single-arm, uncontrolled studies of very small
cohorts with limited follow-up. It was not possible
to pool data across studies, and we are therefore
limited to a narrative summary with very little com-
parative data. Nevertheless, some interesting obser-
vations and inferences can be made.
Two separate multicentered studies from the
United States and Canada have reported an
access-related bacteremia rate of 0.08 episodes per
1000-AVF-days, for in-center hemodialysis patients
using rope-ladder cannulation with native arterio-
venous stulae (57,58). Many studies included in
the present review reported rates up to 4-fold
higher, but lower than many reported rates of bac-
teremia associated with catheter use (0.50 to 1.30
per 1000 AVF-days) (58,59). Some centers, includ-
ing our own, have previously considered the
reported cases of bacteremia with buttonhole cann-
ulation to be cause for alarm (31,36,43). We docu-
mented a S. aureus bacteremia rate of 0.005 per
1000 AVF-days among in-center hemodialysis
patients using rope-ladder cannulation (with 566
patient-years follow-up), during the same era in
which the corresponding rate in home nocturnal
hemodialysis patients was 0.28 per 1000 AVF-days
with buttonhole cannulation. Unfortunately, in our
centers comparison, as with other studies included
in this review, such indirect comparisons do not
adjust for the many differences in patient charac-
teristics.
Several additional factors may account for the
variability in published infection rates, and limit the
comparability across studies. Regardless of vascular
access type or cannulation method, signicant
between-facility variability in access-related infection
rates exists (58). This may reect differences in pop-
ulations as well as practices and technical expertise.
Such differences may be further exaggerated by the
introduction of a new cannulation method.
Although the overall local and systemic infection
rates with home and center dialysis were similar,
they are not directly comparablepatients undergo-
ing dialysis at home generally tend to be younger
and healthier, and their baseline risk for infection
may be lower than that of the overall hemodialysis
population (60). Again, there are limited available
data describing baseline infection rates with rope-
ladder cannulation in the lower risk home dialysis
population. Follow-up time probably also accounts
for some of the variance in infection rates. Studies
with relatively short follow-up did indeed appear to
have low infection rates in this review, while longer
term studies had higher rates. Labriola et al. did
not measure a greater rate of infection until 2 years
472 Grudzinski et al.
after adopting buttonhole cannulation in their facil-
ity (4). Similarly, the trial by MacRae et al.
reported a single episode of bacteremia during
8 weeks of study follow-up, but 2 additional bac-
teremic episodes and 9 additional local infections
with abscess formation within 1 year of study initia-
tion (54). It is therefore likely that many shorter
term studies underestimate the risk of infection with
the buttonhole technique. Finally there is probably
some degree of publication bias in this body of evi-
dence, although it is not clear whether facilities with
better or worse outcomes are more likely to report
their ndings.
Given these considerations, there remains consid-
erable uncertainty as to the risk of infection with
buttonhole cannulation. Moreover, most studies
included in this review had established expertise
with buttonhole cannulation. If the risk of infection
is operator-dependent, then centers without prior
expertise may experience greater rates of infection
than have been reported to date.
The current literature provides some limited
insights into modiable practices that may reduce
infections in patients using buttonhole cannulation.
The study by Labriola et al. suggests a degree of
operator-dependence, and that careful training and
expertise are important determinants of infection
risk (4). Skin antisepsis methods, scab removal tech-
nique, the puncture itself, and overall aseptic tech-
nique are also probably relevant factors, but their
relative importance is unclear. The only two studies
included in this review that used topical antimicro-
bial prophylaxis reported no infections while the
intervention was in use. Interestingly, both studies
also reported local and systemic infection after
adopting a topical antimicrobial prophylaxis proto-
col, and in all cases, affected patients later admitted
to nonadherence with the prophylactic regimen
(36,43). While no studies reported emergence of
mupirocin resistance, it is a theoretical risk that
should be considered, and local policies for screen-
ing for mupirocin resistance should be followed.
Nevertheless, these preliminary observational data
suggest some promise and provide justication for
more rigorous study.
Available data describing long-term patency and
complication rates were limited as well. While the
study by Ward reported fewer endovascular inter-
ventions after converting to buttonhole cannulation,
the study used a crossover design, and existing ana-
tomical problems may have been addressed prior to
converting to buttonhole cannulation (42). The
study by van Loon documented fewer interventions
with buttonhole cannulation, but the comparator
group consisted of patients using rope-ladder cann-
ulation at two different facilities (40). The compari-
son did not adjust for between-patient differences,
and important prognostic factors such as access vin-
tage and prior access complications were not
described. This analysis may therefore be limited by
signicant residual confounding. Nevertheless, the
suggested signal of benet is supported by
observations from other studies. Our center did not
document any episodes of permanent access aban-
donment in a cohort of 56 patients followed for a
total of 287 patient-years (36). The study by Marti-
corena reported regression of aneurysm in two
patients (44).
The potential impact of buttonhole cannulation
on aneurysm formation has been of interest, and
has been reported in a number of studies. While
aneurysmal dilatation is typically a late complica-
tion for patients with stulae, the risk of bleeding,
high-output heart failure, and permanent access
abandonment may be signicant (61). Unfortu-
nately, the use of aneurysmal dilatation as an
outcome is limited by lack of standardization in
measurement and reporting methods, and by uncer-
tainty surrounding the prognostic signicance of an
aneurysm. While an aneurysm can lead to shorter
usable segments, and the above-mentioned compli-
cations, aneurysmal stulae may often be used with-
out difculty or major sequelae over the long-term.
If aneurysmal dilatation is be used as an early pre-
dictor of long-term patency, it should be validated
as a surrogate outcome, and standardization of
measurement and reporting methods would be of
value. In the meantime, it seems reasonable that
patients with short usable segments due to aneu-
rysm formation may benet from buttonhole cannu-
lation, as an alternative to permanent access
abandonment.
Finally, a number of studies examined the effect
of buttonhole cannulation on cannulation-related
pain. Most included studies used a 10-point visual
analog scale, and scores generally averaged <3 out
of 10. Observational and crossover studies sug-
gested improvement in pain scores, which in many
cases were statistically signicant (33,37,46), but
with mean differences of 0 to 0.6 on a 10-point
scale (33,41). None of the included reports
described any validation studies, measurement
properties, or established minimal important differ-
ence measures for their pain instruments (62), and
the clinical signicance of these relatively small
changes in pain scores is questionable. Moreover,
when measured in the context of a clinical trial, in
which the confounding effect of topical anesthetics
was removed, no difference in pain scores (using
the same 10-point visual-analog scale) was detected
(54).
Strengths and Limitations of this Review
This was a pragmatic systematic review, which
we conducted in lieu of a less rigorous narrative
review of selected studies. We used a high-specic-
ity search strategy, which may have resulted in
some degree of study selection bias. However, we
also included a representative range of medical and
allied health care databases, and recent meeting
abstracts from a major nephrology meeting. We
had specied a priori that included studies should
report outcomes for home and center patients
BUTTONHOLE CANNULATION REVIEW 473
separately; this resulted in one clinical trial being
excluded, although its inclusion would not have
altered the nal conclusions of this review (25).
We focused on outcomes that we considered the
most important from a patient perspective, and did
not examine nurse satisfaction, hemostasis, minor
bleeding, or unsuccessful cannulation attempts.
Moreover, we did not identify any reports that
described major bleeding episodes, although this is
an important theoretical risk with any cannulation
technique.
Implications for Clinical Practice
Since its advent over 3 decades ago, the button-
hole cannulation technique has not yet been broadly
adopted. Interestingly, the original description of
the rst successful use of the buttonhole technique
was among patients with cannulation difculties
due to pain and anatomical problems (1). In its rst
incarnation, buttonhole cannulation was intended
for these selected indications, and not for general
use by all patients receiving hemodialysis with a s-
tula. Based on the current published experience, this
approach still appears reasonable. Until the risks
and strategies to mitigate potential risks are better
understood, the use of buttonhole cannulation
might best be restricted to patients with anatomical
problems, and those in need of a less technically
demanding procedure, especially in the home set-
ting, or for self-cannulation (63).
Implications for Future Research
To date, three small clinical trials evaluating
buttonhole cannulation have been completed
(25,39,54), and a fourth study with a published pro-
tocol awaits nal publication (16). In general, small
explanatory trials can provide useful insights into
questions pertaining to efcacy (e.g., patient satis-
faction, pain), when adequately powered. As is
commonly the case, rare events, such as infectious
complications, require longer term follow-up, and
larger patient samples. Although the absolute risk
of infection may appear to be relatively low, if mul-
tiplied across entire hemodialysis patient popula-
tions, the actual number of potentially catastrophic
infections may be unacceptably high. Before button-
hole cannulation can be adopted on a larger scale,
larger studies providing more precise estimates of
infection risk are needed. Until a large clinical trial
with long-term follow-up becomes feasible, prospec-
tive observational studies will probably provide the
best possible evidence within a reasonable time
frame.
Acknowledgments
The authors are grateful to Ms. Julie Waddick for her
expert guidance in developing our literature search strate-
gies.
References
1. Twardowski Z: Different sites versus constant sites of needle insertion
into arteriovenous stulas for treatment of repeated dialysis. Dial
Transplant 8:978980, 1979
2. Silva GDST, Silva RAd, Nicolino AM, Pavanetti LC, Alasmar VL,
Guzzardi R, Zanolli MB, Guilhen JC, Araujo IdM: Initial experience
with the buttonhole technique in a Brazilian hemodialysis center. J
Bras Nefrol 32:257262, 2010
3. Doss S, Schiller B, Moran J: Fistula rst: vascular access update. But-
tonhole cannulation an unexpected outcome. Nephrol Nurs J
35:417419, 2008
4. Labriola L, Crott R, Desmet C, Andre G, Jadoul M: Infectious com-
plications following conversion to buttonhole cannulation of native
arteriovenous stulas: a quality improvement report. Am J Kidney Dis
57:442448, 2011
5. Guyatt G, Montori V, Devereaux P, Schunemann H, Bhandari M:
Patients at the center: in our practice, and in our use of language.
ACP J Club 140:A11A12, 2004
6. Buscemi N, Hartling L, Vandermeer B, Tjosvold L, Klassen TP: Sin-
gle data extraction generated more errors than double data extraction
in systematic reviews. J Clin Epidemiol 59:697703, 2006
7. Ball LK, Mott S: How do you prevent indented buttonhole sites?
Nephrol Nurs J 37:427428, 431, 2010
8. Deaver K: CNE: Continuing Nursing Education. Preventing infections
in hemodialysis stula and graft vascular accesses. Nephrol Nurs J
37:503506, 2010
9. Flynn A, Linton A: Buttonhole cannulation principles. Ren Soc Aust
J 7:9093, 2011
10. Murcutt G: Buttonhole cannulation: should this become the default
technique for dialysis patients with native stulas? Summary of the
EDTNA/ERCA Journal Club discussion Autumn 2007. J Ren Care
34:101108, 2008
11. Ward F, Holian J, Watson A: Arteriovenous stula buttonhole cannu-
lation: early experience in an Irish haemodialysis unit. Nephrol Dial
Transplant 26:3825; author reply 1825-6, 2011
12. Peterson P: Clinical consult. Fistula cannulation: the buttonhole tech-
nique. Nephrol Nurs J 29:195, 2002
13. Macrae JM, Tai DJ, Daniw M, Lee J: A simple method to create but-
tonhole cannulation tracks in a busy hemodialysis unit. Hemodial Int
14:9495, 2010
14. Kregness A: Believing in the buttonhole technique. Nephrol News
Issues 22:36, 2008
15. Galante NZ, Yamamoto A, Rabelo LL, Monterio DP, Azevedo LS:
Buttonhole: an old technique rediscovered. J Bras Nefrol 33:115117,
2011
16. King J: Implementing the buttonhole method using the Biohole peg in
a busy dialysis unit: a report of the development of current practice. J
Ren Care 35:192200, 2009
17. Ball LK, Treat L, Rife V, Scherting D, Swift L: Fistula rst: vascular
access update. A multi-center perspective of the buttonhole technique
in the Pacic Northwest. Nephrol Nurs J 34:234241, 2007
18. Birchenough E, Moore C, Stevens K, Stewart S: CNE: Continuing
Nursing Education. Buttonhole cannulation in adult patients on he-
modialysis: an increased risk of infection? Nephrol Nurs J 37:491499,
2010
19. Kumbar L: Complications of arteriovenous stulae: beyond venous
stenosis. Adv Chronic Kidney Dis 19:195201, 2012
20. Labriola L, Desmet C, Andre G, Goovaerts T, Jadoul M: Semiblunt
needles for buttonhole cannulation: is outcome better? Hemodialysis
International Conference: Annual Dialysis Conference - 30th Annual
Conference on Peritoneal Dialysis, 16th International Symposium on
Hemodialysis, and 21st Annual Symposium on Pediatric Dialysis Seat-
tle, WA United States. Conference Start: 20100307 Conference
End: 20100309. Conference Publication: (var.pagings). 14 (1) (pp 101),
2010
21. Mott S, Moore H: Clinical Consult. Kinder, Gentler Methods for
Scab Removal In Buttonhole Access. Nephrol Nurs J 38:439443, 2011
22. Ball LK: The buttonhole technique for arteriovenous stula cannula-
tion. Nephrol Nurs J 33:299305, 2006
23. Ball LK: CNE: Continuing Nursing Education. The buttonhole tech-
nique: strategies to reduce infections. Nephrol Nurs J 37:473478, 2010
24. Hartig V, Smyth W: Everyone should buttonhole: A novel tech-
nique for a regional australian renal service. J Ren Care 35:114119,
2009
25. Chow J, Rayment G, Miguel SS, Gilbert M: A randomised controlled
trial of buttonhole cannulation for the prevention of stula access
complications. J Ren Care 37:8593, 2011
26. Mott S, Moore H: Fistula rst: vascular access update. Using tandem
hand technique to facilitate self-cannulation in hemodialysis. Nephrol
Nurs J 36:313, 2009
27. Hsiao J-F, Chou H-H, Hsu L-A, Wu L-S, Yang C-W, Hsu T-S,
Chang C-J: Vascular changes at the puncture segments of arteriove-
nous stula for hemodialysis access. J Vasc Surg 52:669673, 2010
474 Grudzinski et al.
28. Showers M, Chan C, Glickman JD: Buttonhole use in HHD: the pro-
cedure and why. Nephrol Nurs J 35:179, 2008
29. Figueiredo AE, Viegas A, Monteiro M, Poli-de-Figueiredo CE:
Research into pain perception with arteriovenous stula (avf) cannula-
tion. J Ren Care 34:169172, 2008
30. Galante NZ, Rabelo LL, Yamamoto A, Bonato RA, Azevedo LS:
One units experiences when establishing buttonhole technique, analy-
sis of reasons for failure of procedure: a report. J Ren Care 36:7380,
2010
31. Gray N: The risk of sepsis from buttonhole needling must be appreci-
ated. Nephrol Dial Transplant 25:23852386; author reply 2386, 2010
32. Hashmi A, Cheema MQ, Moss AH: Hemodialysis patients experience
with and attitudes toward the buttonhole technique for arteriovenous
stula cannulation. Clin Nephrol 74:346350, 2010
33. Ludlow V: Buttonhole cannulation in hemodialysis: improved out-
comes and increased expenseIs it worth it? CANNT J 20:2937, 2010
34. Leitch R, Ouwendyk M, Ferguson E, Clement L, Peters K, Heiden-
heim AP, Lindsay RM: Nursing issues related to patient selection,
vascular access, and education in quotidian hemodialysis. Am J Kidney
Dis 42:5660, 2003
35. Lindsay RM, Leitch R, Heidenheim AP, Kortas C: The London
Daily/Nocturnal Hemodialysis Studystudy design, morbidity, and
mortality results. Am J Kidney Dis 42:512, 2003
36. Nesrallah GE, Cuerden M, Wong JHS, Pierratos A: Staphylococcus
aureus bacteremia and buttonhole cannulation: long-term safety and
efcacy of mupirocin prophylaxis. Clin J Am Soc Nephrol 5:1047
1053, 2010
37. Pergolotti A, Rich E, Lock K: The effect of the buttonhole method
vs. the traditional method of AV stula cannulation on hemostasis,
needle stick pain, pre-needle stick anxiety, and presence of aneurysms
in ambulatory patients on hemodialysis. Nephrol Nurs J 38:333336,
2011
38. Quinan P: Buttonhole technique. CANNT J 18:4446, 2008
39. Toma S, Shinzato T, Fukui H, Nakai S, Miwa M, Takai I, Maeda K:
A timesaving method to create a xed puncture route for the button-
hole technique. Nephrol Dial Transplant 18:21182121, 2003
40. van Loon MM, Goovaerts T, Kessels AGH, van der Sande FM, Tor-
doir JHM: Buttonhole needling of haemodialysis arteriovenous stulae
results in less complications and interventions compared to the rope-
ladder technique. Nephrol Dial Transplant 25:225230, 2010
41. Verhallen AM, Kooistra MP, van Jaarsveld BC: Cannulating in hae-
modialysis: rope-ladder or buttonhole technique? Nephrol Dial Trans-
plant 22:26012604, 2007
42. Ward J, Shaw K, Davenport A: Patients perspectives of constant-site
(buttonhole) cannulation for haemodialysis access. Nephron 116:c123
c127, 2010
43. Marticorena RM, Hunter J, Cook R, Kashani M, Delacruz J, Peter-
shofer E, Macleod S, Dacouris N, McFarlane PA, Donnelly SM,
Goldstein MB: A simple method to create buttonhole cannulation
tracks in a busy hemodialysis unit. Hemodial Int 13:316321, 2009
44. Marticorena RM, Hunter J, Macleod S, Petershofer E, Dacouris N,
Donnelly S, Goldstein MB: The salvage of aneurysmal stulae utiliz-
ing a modied buttonhole cannulation technique and multiple cannu-
lators. Hemodial Int 10:193200, 2006
45. Marticorena RM, Hunter J, Macleod S, Petershofer E, Kashani M,
De La Cruz J, Cook R, Dacoiris N, McFarlane PA, Goldstein MB,
Donnely SM: Use of the BioHoleTM device for the creation of tunnel
tracks for buttonhole cannulation of stula for hemodialysis. Hemo-
dial Int 15:243249, 2011
46. Castro MCMd, Silva CdFe, Souza JMRd, Assis MCSBd, Aoki
MVdS, Xagoraris M, Centeno JR, Souza JACd: Arteriovenous stula
cannulation by buttonhole technique using dull needle. J Bras Nefrol
32:281285, 2010
47. Van Eps CL, Jones M, Ng T, Johnson DW, Campbell SB, Isbel NM,
Mudge DW, Beller E, Hawley CM: The impact of extended-hours
home hemodialysis and buttonhole cannulation technique on hospital-
ization rates for septic events related to dialysis access. Hemodial Int
14:451463, 2010
48. Lok CEKS, Chan CT, Zimmerman DL: Frequent Hemodialysis Fis-
tula Infectious Complications. Abstract SA-OR460 at: American Soci-
ety of Nephrology 2011 Meeting; Nov. 8-13, 2011; Philadelphia, PA,
2011
49. Muir CAKS, Hawley CM, Gallagher MP, Snelling P, Jardine MJ: But-
tonhole Versus Sharp Needle Cannulation: Clinical Outcomes in a
Home Hemodialysis Cohort. Abstract FR-PO1950 at: American Society
of Nephrology 2011 Meeting; Nov. 8-13, 2011; Philadelphia, PA, 2011
50. Nesrallah GCM, Wong J, Pierratos A: S. Aureus Bacteremia in
Patients Receiving Home Nocturnal HD Using Button-Hole Cannula-
tion with AV Fistulae: Long-Term Safety and the Efcacy of Prophy-
lactic Antimicrobial Cream. Abstract SA-PO2501 at: American
Society of Nephrology 2009 Meeting; Oct. 27-Nov. 1, 2009; San
Diego, CA, 2009
51. Backenroth RIR, Rubinger D: Comparison of Native Arterio-Venous
(A-V) Fistula Needling Using the Button-Hole Versus the Rotation
Technique. Evidence for Excess Blood Stream Infections with the But-
ton-Hole Method. Abstract F-PO1554 at: American Society of
Nephrology 2010 Meeting; Nov. 16-21, 2010; Denver, CO, 2010
52. Leitch R, Ouwendyk M, Ferguson E, Clement L, Peters K, Heiden-
heim AP, Lindsay RM: Nursing issues related to patient selection,
vascular access, and education in quotidian hemodialysis. Am J Kidney
Dis 42:S56S60, 2003
53. Lindsay RM, Leitch R, Heidenheim AP, Kortas C: The London
Daily/Nocturnal Hemodialysis Study study design, morbidity, and
mortality results. Am J Kidney Dis 42:S5S12, 2003
54. Macrae JM, Ahmed SB, Atkar R, Hemmelgarn BR: A randomized
trial comparing buttonhole with rope ladder needling in conventional
hemodialysis patients. Clin J Am Soc Nephrol 7:16321638, 2012
55. Muir C, Kotwal S, Hawley C, Snelling P, Park Y, Gallagher M, Jar-
dine M: Buttonhole versus ropeladder cannulation: Association with
clinical outcomes in a home haemodialysis cohort. Nephrology Confer-
ence: 47th Annual Scientic Meeting of the Australian and New Zea-
land Society of Nephrology Adelaide, SA Australia. Conference Start:
20110919 Conference End: 20110921. Conference Publication: (var.pa-
gings). 16 (pp 30), 2011
56. Nesrallah GE, Suri RS, Moist LM, Cuerden M, Groeneweg KE,
Hakim R, Ofsthun NJ, McDonald SP, Hawley C, Caskey FJ, Couc-
houd C, Awaraji C, Lindsay RM: International Quotidian Dialysis
Registry: annual report 2009. Hemodial Int 13:240249, 2009
57. Tokars JI, Miller ER, Stein G: New national surveillance system for
hemodialysis-associated infections: initial results. Am J Infect Control
30:288295, 2002
58. Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S, Cana-
dian Hospital Epidemiology Committee. Canadian Nosocomial Infec-
tion Surveillance P: Prospective surveillance for primary bloodstream
infections occurring in Canadian hemodialysis units. Infect Control
Hosp Epidemiol 23: 716720, 2002
59. Dryden MS, Samson A, Ludlam HA, Wing AJ, Phillips I: Infective
complications associated with the use of the Quinton Permcath for
long-term central vascular access in haemodialysis. J Hosp Infect
19:257262, 1991
60. Nesrallah GE, Lindsay RM, Cuerden MS, Garg AX, Port F, Austin
PC, Moist LM, Pierratos A, Chan CT, Zimmerman D, Lockridge RS,
Couchoud C, Chazot C, Ofsthun N, Levin A, Copland M, Courtney
M, Steele A, McFarlane PA, Geary DF, Pauly RP, Komenda P, Suri
RS: Intensive hemodialysis associates with improved survival com-
pared with conventional hemodialysis. J Am Soc Nephrol 23:696705,
2012
61. Schinstock CA, Albright RC, Williams AW, Dillon JJ, Bergstralh EJ,
Jenson BM, McCarthy JT, Nath KA: Outcomes of arteriovenous s-
tula creation after the Fistula First Initiative. Clin J Am Soc Nephrol
6:19962002, 2011
62. Jaeschke R, Singer J, Guyatt GH: Measurement of health status.
Ascertaining the minimal clinically important difference. Control Clin
Trials 10:407415, 1989
63. Nesrallah GE, Mustafa RA, Macrae J, Pauly RP, Perkins DN, Gangji
A, Rioux JP, Steele A, Suri RS, Chan CT, Copland M, Komenda P,
McFarlane PA, Pierratos A, Lindsay R, Zimmerman DL: Canadian
society of nephrology guidelines for the management of patients with
ESRD treated with intensive hemodialysis. Am J Kidney Dis 62:187
198, 2013
BUTTONHOLE CANNULATION REVIEW 475