Arteriovenous fistula survival with buttonhole (constant site) cannulation for hemodialysis access

Buttonhole needling for arteriovenous fistulae (AVF) has increased in popularity among dialysis centers. Concerns have been raised about the risks of infection, so we reviewed our experience of buttonhole needling in 227 adult patients on hemodialysis. The mean buttonhole AVF survival was 27.0 months, in 227 patients, 61.1% male, mean age 63.8 ± 15.5 years, 45.8% with diabetes mellitus, median dialysis vintage 19 months (6.5-42.8). Ninety-six patients transferred to rope ladder AVF cannulation, because of cannulation failure in 25%, persistent bleeding at the needling site in 24%, fistula thrombosis in 14%, and infections in 15%. Because of persistent methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant S. aureus (MRSA) colonization, 18.8% discontinued buttonhole needling. Transfer from buttonhole needling was more common for people with diabetes (X = 6.57; p = 0.035), older patients (odds ratio, 0.985; p = 0.007), and persistent MSSA/MRSA colonization (odds ratio, 0.88; p = 0.037). Eleven episodes of suspected buttonhole S. aureus bacteremia occurred giving a bacteremia rate of 2.94 per 100 patient years, and 15 local infections giving an infection rate of 4.01 per 100 patient years. In this large series of buttonhole AVF access, although infection rates were increased, more patients discontinued buttonhole needling because of technical cannulation problems and persistent bleeding from needle tracks.