The Buttonhole Technique: How to Convert a Fistula into a Catheter

Abstract

The buttonhole technique (BT) is an alternative to the standard needling for the cannulation of arterio-venous fistula (AVF). The balance between benefits and harms associated with the BT is unclear. In order to analyze the recent literature we searched PubMed for “randomized controlled study on buttonhole” and “review of buttonhole cannulation”, published between January 2011 and November 2013. We identified 3 randomized trials and 3 reviews. One randomized trial showed a better survival of the AVFs (100% vs 82%), fewer interventions (19% vs 39%), and lower growth of pre-existing aneurysms (23% vs 67%) in the BT group. A second study showed a greater number of infections and hematomas, and a greater perception of pain in the BT group. A third study showed no differences in perception of pain and bleeding time between the BT group and the control group; additionally, it reported a greater number of hematomas in the control group and a greater number of local infections and sepsis in the BT group. The three reviews showed no definite results regarding the various endpoints of BT (perception of pain, aneurysm formation, bleeding time), and confirmed the increased risk of local and systemic infections. Based on this analysis, we can conclude that the BT produces an increased risk of local and systemic infections without definite benefits. Recent studies suggest reserving the BT in selected cases (vessels particularly deep or too short stretches). However, we cannot exclude that further randomized controlled trials may lead to different conclusions on the BT.