Buttonhole Tunnel Tract Creation with the BioHole® Buttonhole Device

Cannulation, and in particular, skilled cannulation is the cornerstone to preserving the arteriovenous fistula, the lifeline for a patient receiving long-term hemodialysis therapy. The buttonhole cannulation method has seen a huge revival in the 2000s, but it can sometimes prove challenging to implement successfully. This chapter discusses and describes the method of creating a buttonhole tract using the BioHole® device (a sterile polycarbonate peg), and describes the associated advantages and disadvantages. In a busy hemodialysis unit, use of the thumbtack-shaped 5-mm peg allows a fixed puncture route to be created quickly in just 7-14 days. The peg is placed at the site where the sharp puncture needle has just been removed by the designated primary cannulator. The peg remains in place until the next dialysis session when it is removed, the dialysis therapy completed as usual, and a new peg is inserted after hemostasis has been achieved. These steps are repeated for 1-2 weeks. Once the tunnel is formed, use of the peg is no longer needed and a blunt-ended puncture needle is inserted along the track each time. Buttonhole cannulation using the BioHole peg device offers advantages including reduced risk of needling complications and arteriovenous fistula failure, speedy transition to blunt needles, the tunnel track remaining narrow thus reducing the risk of developing an exit site infection, and suitability in difficult sites. Possible disadvantages are increased cost for purchase of the pegs during the track break-in period and potential complications such as discomfort, bleeding, and risk of infection. These risks/disadvantages minimize after the transition to blunt needles which in itself is a safer option than using sharp needles. As supported by KDOQI (2006) and the UK Renal Association (2011), adoption of the buttonhole method as the cannulation technique of choice is recommended in the majority of patients undergoing hemodialysis who have a native fistula.