Managing ‘buttonhole’ complications

Surendra Shenoy MD., PhD.Washington University School of Medicine

Barnes Jewish HospitalSt. Louis, Missouri

Disclosures

Laboratory and clinical research support from industry for

research related to transplant and vascular access

None of the research or non FDA approved products will be discussed in this

presentation

S.Shenoy©

How to access a fistula?

Cannulation techniques

Rope ladder technique

Area cannulation

Buttonhole cannulation

90◦ 45◦ 20◦

Terminology for AVF assessment

Vein depth

Skin

Vein

1.5mm 3 mm 5 mm

Tract length

Skin puncture

Vein puncture

Access needles and

6mm

placement

Bevel 6mm

Needle 2.6cm

Bevel 4mm

1 inch = 2.6 cm = 26 mm

Hemostasis following needle withdrawal & what is safe?

Aim for a tract of 6 - 9mm

Button hole technique

Tract 9.7mm

Vasculo –cutaneous fistula

Buttton hole – vasculo-cutaneous fistula

Key components- Obliquity of tract- Length of tract 6-9mm

Advantages of ‘Buttonhole’

Twardowski Z. Dial. Tran. ‘79; 8:9781 Lindsey RM, et. al. AJKD ‘03; 42:5Van Loon MM, et. al. NDT 10;25:225 Varhallen AM. NDT ‘07;22:260Kim M. HD Inter 2013;17:294

Less painNo local analgesicDecreased hemostasis timeBetter for self cannulationLess infiltrationLess hematomaNo aneurysmsUseful in limited access siteBetter patient acceptance

Challenges to create buttonholes

• Patient schedule and staff schedule do not match• Deep veins with high body mass index• Scab removal difficulties and techniques• Advancement to blunt needle• Inadequate BH formation• Cannulation during patient hospitalization• Increased missed cannulations

Ball LK. Neph nurs 2006;33:299Toma ST. ADC 2005; Tampa

Buttonhole complications

Infection- Contact dermatitis- Needle insertion site infection - Septicemia hospital admission in NHD

Staphylococcus Aureus

Van EPS CL. HD Int. 2010;14:451Nesrallah GE et.al CJASN 2010;5: 1047

Contact dermatitis

Identify the offending agente.g. Tape, topical ointments, dressing, chlorhexedine

Local infection

Local infection - surgical management

NO Catheter

Potential reasons for problems

Sub clinical infiltration

Secondary infection

Infiltrate getting infected

Cause for infiltration

Improper creation of ‘Buttonhole’

Short tracts

When fistula outflow is superficialKeep needle as parallel to skin as possible

Stick on sideof vessel

Not on top

Lateral approachfor cannulation

Shorttract

Short tractbleeding

Managing Buttonhole infections

Aseptic techniqueStaff trainingTopical antibiotic useCreating better buttonholes‘Biohole’ device or ‘Clampcath’

Marticorena RM. HD Int. 2006; 10:193Toma S. Neph Dial 2003;18:2118Nesrallah GE. CJASN2010; 5:1047

SummaryButton hole or single site puncture

technique has significant advantage andspecific applications in certain AVF

situation Tract length and obliquity are extremelyimportant for the safety and function of

this technique

Standardization of creation and care usingpatient and staff education may be beneficial

for increasing the safety and utility