buttonhole….a technique which is still evolving! tony goovaerts clinques universitaires st. luc...
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Buttonhole….a technique which is still evolving!
Tony GoovaertsClinques Universitaires St. LucBrussel, België
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Literature (1)
• During the neighties almost no literature on actual puncture techniques
• Since buttonhole has become popular,…. many publications
• A lot of controversy• Main concern: infections!
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Literature (2)
• Huge differences between centres, countries, continents,…..
• Infection rates ranging from 0.05 (Vaux et al) tot 0.39 (Muir et al) per 1000 fistula days
• Poorly description of technique!!!!!Serv
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Puncture techniques
Rope ladder
Regional
Buttonhole
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Rope ladder punctureSe
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Regional or area puncture
Small puncture area with:
Thinning of the vessel wallAneurismal formationStenosisOozingLonger bleeding times after needle removal
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Results of the Cox model with primary outcome vascular access survival
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Parisotto et al.
Establishing Tunnel Track
• Standard procedure• Biohole procedure• CatheterSe
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BioHole Buttonhole Device*
Support unit
Support unit
plug
plug
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Advantages of the BioHole Device
• No single cannulator?• Faster tunnel track formation• Better tunnel track formation• Now available in 3 lenghts
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Removal of scabsSe
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Soaking of scabs
• Saline• Alcohol gel• Emla• Chlorhexidine creme• Disinfecting Soap• ……
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Some key points
•Tourniquet?
•Trampoline effect!
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Buttonhole Wrong Angle!
• Arm always in same position• Angle has to be adjusted to be in
alignment with vessel entrance• Pull back needle till point reach the
entrance of tunnel to redirect towards vessel entrance
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Touch CannulationSe
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Touch CannulationSe
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Cannulation challenges
BUTTONHOLE IMPLEMENTATIONDEEP / UNCANNULATABLE
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VWING VASCULAR NEEDLE GUIDE
VWINGSurgically-placed, subcutaneous vascular needle guide
GUIDE
Guides needle directly to vessel through
same pathway every time, rapidly
enabling use of blunt needles via
simplified buttonhole cannulation.
TARGET
Serves as palpable target
to facilitate dialysis cannulation.Serv
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DEEP AVFNON-TRANSPOSED BASILIC
SHORT SEGMENT AVF
AVOID AREAS OFANEURYSM OR DAMAGE
SELF CANNULATION
BUTTONHOLE CANNULATION
Vwing ApplicationsSe
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Different sizes
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Self cannulation
Obese patient with inaccessible flowing fistulaVWING implanted – fistula accessedQuickest to self-cannulate at dedicated home hemo training unit
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• Initial VWING implant has been used for over 3.6 years since June 2010
VWING Clinical Use Summary
IMPLANT HISTORY Patients Devices
VWING Patient Total / Implanted VWING Total 141 216
Patient Implant Days / Device Implant Days 46,7002 72,5002
Cannulations N/A 23,8002
Jan 31, 2014
COMPLICATION RATES (per patient year)
Catheter (USRDS)
AV Fistula (USRDS)
VWING SAVE Study Rate1
VWING Overall Reported Rate1,2
Infection of Access 1.45 0.18 0.038 0.016
Sepsis 2.32 0.52 0.038 0.008
1 – Hospital-treated events 2 – Rates estimated from clinical trial reports and post-market surveillance
Blunt ”double lumen” needleSe
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14 G18 G
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Blunt ”double lumen” needle
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New method that enables complete removal of the scab
Takahiro Shinzato
The7th World Congress of the International Society for Hemodialysis
Daiko Medical Engineering Research Institute, Nagoya,
Japan Shigeki Toma
Toma Clinic, Okinawa,
Japan
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Bleeding must be completely stopped.
Characteristics of moist-healing method
The wound must be kept moist.
1.
2.
3.
The wound must be disinfected with diluted Povidone iodineSe
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0 fold
isodine
J-iode
50 100 150 200 250 300
250
200
150
100
50
0
free
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Matsuoka et al: The 10th peritoneal dialysis conference
Dilution ratio of povidone iodine solution
（ μg/mL ）
®
®
and free iodine concentration
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Staphylococcus aureus
Staphylococcus epidermidis
Enterococcus
E. Coli
Pseudomonas aeruginosa
bacterias
Bacteriocidal activity of povidone iodine solution is highest when commercial solution is diluted 100-fold.
bacteriocidal activity
No Yes
original solution
50-fold dilution
100-fold dilution
No
No YesNo
NoNo No
Yes Yes Yes
Yes Yes Yes
Matsuoka et al: The 10th peritoneal dialysis conference
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Immediately after we disinfect the buttonhole entry site, we apply an anti-microbial film dressing to the site.
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The anti-microbial film dressing is removed after 24 hours
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Results of moist-healing application to buttonhole entry site
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Scab removal during bathing
towel
Stratum corneum
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＜ 24 hours after application of the dressing＞
＜ after hemodialysis＞＜ at the time of next dialysis＞
anti-microbial film dressing
＜ in bath a day before the next hemodialysis＞
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outside
insideneutrophils neutrophils
nuclei
Results of histological examination of thin membrane formed at the buttonhole entry site
Fibrin deposits
Stratum corneum
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skin disinfected with diluted
Skin disinfected with non-diluted solution
or non-diluted povidone iodine solution
Skin disinfected with diluted solution
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• Inclusion criteria– All patients dialysing in « Carpe Diem »– Between 1990 and 2012– With functional AVF
• Events of interest– Local infection– Bacteremia– Combined infection
Population and events
Buttonhole cannulation
1990 1998 2012
Rope-ladder
SWIT
CH
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1st period 2nd period Number of patients 68 115Number of AVF-days 57851 97911Age (y) 45,8 (20,4) 46,9 (20,4)Men 39 (57,3) 70 (60,9)Underlying nephropathy Diabetic 1 (1,5) 9 (8,0)Glomerulonephritis 21 (31,8) 44 (39,2)Vascular 4 (6,1) 8 (7,1)Polycystic kidney disease 15 (22,7) 22 (19,6)Uropathy 1 (1,5) 3 (2,7)Chronic interstitial nephritis 17 (25,8) 13 (11,6)Other nephropathy 7 (10,6) 13 (11,6)Diabetes 2 (2,99) 11 (9,8)Transplantation before HD initiation 10 (14,7) 18 (15,8)Immunosuppressive therapy at HD initiation 14 (20,6) 24 (21,0)
Study population
• Characteristics
Values expressed as mean (IQR) or number (rate)
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50
Results
Incidence of infectionsInfectious event 1st period 2nd periodLocal infection (alone)number 2 7incidence rate (per 1000 AVF-days) 0,03 0,07Bacteremia (alone)number 0 2incidence rate 0 0,02Combined local infection and bacteremianumber 1 4incidence rate 0,02 0,04All infectionsnumber 3 13incidence rate 0,05 0,13
Exact Fisher test:p=0,44
Comparison of incidence?
Incidence rate expressed for 1000 AVF-days
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Infection per patient
Patient 1
1990
2013
1995
2000
2005
2010
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8Patient 9
Patient 10
Patient 11
Patient 12
New measures after first infection
• New tunnel tracks• Topical Mupirocin
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Conclusion
• Buttonhole better than area cannulation• Rigourous aseptic technique is mandatory to
prevent infections• Technique is still evolving• Further (multicentric studies) needed• Encouraged to continue
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Thank you for your attention!
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