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

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!

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

Puncture techniques

Rope ladder

Regional

Buttonhole

Rope ladder punctureSe

Regional or area puncture

Small puncture area with:

Thinning of the vessel wallAneurismal formationStenosisOozingLonger bleeding times after needle removal

Results of the Cox model with primary outcome vascular access survival

Parisotto et al.

Establishing Tunnel Track

• Standard procedure• Biohole procedure• CatheterSe

BioHole Buttonhole Device*

Support unit

Advantages of the BioHole Device

• No single cannulator?• Faster tunnel track formation• Better tunnel track formation• Now available in 3 lenghts

Removal of scabsSe

Soaking of scabs

• Saline• Alcohol gel• Emla• Chlorhexidine creme• Disinfecting Soap• ……

Some key points

•Tourniquet?

•Trampoline effect!

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

Touch CannulationSe

Cannulation challenges

BUTTONHOLE IMPLEMENTATIONDEEP / UNCANNULATABLE

VWING VASCULAR NEEDLE GUIDE

VWINGSurgically-placed, subcutaneous vascular needle 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

DEEP AVFNON-TRANSPOSED BASILIC

SHORT SEGMENT AVF

AVOID AREAS OFANEURYSM OR DAMAGE

SELF CANNULATION

BUTTONHOLE CANNULATION

Vwing ApplicationsSe

Different sizes

Self cannulation

Obese patient with inaccessible flowing fistulaVWING implanted – fistula accessedQuickest to self-cannulate at dedicated home hemo training unit

• 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

14 G18 G

Blunt ”double lumen” needle

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　

Bleeding must be completely stopped.

Characteristics of moist-healing method

The wound must be kept moist.

The wound must be disinfected with diluted Povidone iodineSe

0 fold

isodine

J-iode

50 100 150 200 250 300

Matsuoka et al: The 10th peritoneal dialysis conference

Dilution ratio of povidone iodine solution

（ μg/mL ）

and free iodine concentration

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 YesNo

NoNo No

Yes Yes Yes

Matsuoka et al: The 10th peritoneal dialysis conference

Immediately after we disinfect the buttonhole entry site, we apply an anti-microbial film dressing to the site.

The anti-microbial film dressing is removed after 24 hours

Results of moist-healing application to buttonhole entry site

Scab removal during bathing

Stratum corneum

＜ 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＞

outside

insideneutrophils neutrophils

nuclei

Results of histological examination of thin membrane formed at the buttonhole entry site

Fibrin deposits

Stratum corneum

skin disinfected with diluted

Skin disinfected with non-diluted solution

or non-diluted povidone iodine solution

Skin disinfected with diluted solution

• 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

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)

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

Infection per patient

Patient 1

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

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

Thank you for your attention!

Buttonhole….a technique which is still evolving! Tony Goovaerts Clinques Universitaires St. Luc...

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