Let’s Not Throw Out the Buttonhole “Baby” with the Bathwater

This blog post was made by Dori Schatell, MS, Executive Director, Medical Education Institute on April 14th, 2016.
Let’s Not Throw Out the Buttonhole “Baby” with the Bathwater

Last month, Nephrology Dialysis Transplantation ran a pro and a con article about the buttonhole cannulation technique in their Polar Views in Nephrology column. The good news is that cannulation is now receiving close attention from researchers and clinicians, and the debate is still open—which leaves room for more research and better information about who would best benefit from this technique. But, as a home dialysis advocate, the recommendation of the con article was so adamant that it was troubling to me.

First, a bit of background. Cannulation is, of course, essential for any type of HD with a fistula or graft. In-center, the vast majority of people are cannulated by the clinic staff. Self-cannulation, though, one of a bare handful of rights granted to dialyzors by the Medicare Conditions for Coverage, can enable independence. And, fear of self-cannulation has been identified as a major barrier to home HD.1,2,3 I won’t waste time elaborating on why home HD is a better treatment option than standard in-center—just read the Help, I Need Dialysis! book Dr. Agar and I wrote to learn lots of reasons.

What is buttonhole cannulation? Simply put, it is creating scar tissue channels in a fistula by placing needles in the same spots at the same angle for several treatments in a row; a technique developed by Dr. Zbylut Twardowski in the late 1970s. The end result can look a bit like a 2-holed button. Since chronic dialysis began in the early 1960s, blood access has remained one of its biggest challenges. Advent of the arteriovenous fistula (AVF) in 1966 and the arteriovenous graft (AVG) in 1970 brought a need to repeatedly puncture living tissue to reach the blood instead of connecting a Scribner shunt cannula as had been done before. Alternating needle sites to allow healing seemed prudent and, with virtually no study, became the standard.

(A quick aside: There are two ways to alternate cannulation sites: “rope-ladder”—systematically moving up and down the full length and sides of an AVF or AVG, and “area cannulation—placing needles in the same general spot over and over, which pretty clearly increases aneurysm formation and should never be done. You can see in the images below how aneurysms are starting to form with area cannulation. This is all-too-common and can lead to fatal access rupture.)

Back to the con article. The biggest concern is an increased risk of blood infection. The authors noted that: “Buttonhole cannulation has not been shown to reduce cannulation-related pain, improve vascular access survival, reduce vascular access interventions, reduce haematoma formation, improve haemostasis or reduce aneurysm formation. Consequently, rope-ladder cannulation should remain the standard of care and buttonhole cannulation should only [emphasis mine] be used in rare circumstances (e.g. short segment AVFs where the only alternative is a haemodialysis catheter).

Unfortunately, this conclusion—while meticulously supported by a literature review focusing primarily on randomized controlled trials—left out a vital consideration: the people whose living tissue must be punctured 3, 4, 5, or even 6 times a week by needles the size of fork tines. These are the same people whose fear of self-cannulation could keep them from doing the treatment that might give them the best chance of feeling well and living as long as they can.

So, I queried participants in our Home Dialysis Central Facebook Discussion Group (and alerted them that I would be writing this blog.) “Would YOU have started home HD if you couldn't buttonhole? Would you KEEP doing home HD if you couldn't?” I asked. There were 82 relevant comments from 37 different participants, and they were roughly divided nearly 50/50 into two main groups:

  1. I can deal with the needles, and nothing would keep me from home HD:
    • “Buttonholes made no difference in us deciding HHD…We would continue HHD if we had to use sharps in a heartbeat.”

    • “I need to establish a new venous buttonhole. So I'm going to do it, with the assistance of my center staff. And if I have to do sharps, then so be it. Not going back to incenter treatment.‬‬

    • “IF for some reason I could not buttonhole, I would still stay home. And I would have gone home regardless.”

    • “We were ok with sharps and scab picking was not to our liking.”

    • “With my first fistula I did use buttonholes, and just hated it. I prefer to use sharps and use the rope and ladder method as I personally feel it is what is best for my access.”

  2. Needles scare me—I would not have made it home without buttonholes—but, now that I’m there, nothing would make me go back in-center:
    • “I honestly would have not been willing to give up my CVC if I would have not been able to use the buttonhole technique. I was scared out of my mind to have anyone but me cannulate myself and would never have been able to deal with sharps long term.‬‬”
    • “I have used sharps, and had infections, and severe anxiety. I have used buttonholes exclusively for over 6 years, one infection around the buttonholes but it traveled from elsewhere in the body. No anxiety now, unless someone else tries to access the fistula.
    • “Wouldn't have started HHD without buttonholes…It's the needle phobia thing. It took 9 years to get me home.”
    • “Buttonholes are my lifeline to somewhat of a normal life‬.”

The group made some excellent points about nocturnal HD, in particular, including

  • It is unwise/unsafe to sleep with sharp needles in your arm—the risk of infiltration is too high.
  • It would be extremely helpful to have a flexible cannula option, like an IV, instead of steel needles. (NOTE: plastic cannulas are available in Australia and Canada, but not in the U.S.).
  • Most of the reported studies are of in-center buttonholes, or mix in-center with home and self-cannulation with staff cannulation.
  • When home dialyzors are included, the home environment is not accounted for—some delivery drivers have horror stories of hoarders and such…

Was this query scientific? No. Randomized? No. Is the plural of anecdote data? No again. But, how can any discussion of the pros or cons of buttonhole cannulation be complete if it includes only clinical risks and not the views of the people using the technique—or denied it? How can the authors justify only looking at statistical significance when it comes to the level of pain from blunt vs. sharp needle—and not the variance. Some people feel more pain with one technique, and some with the other. Proposing to deny nearly everyone the opportunity to try the buttonhole technique in this case would simply be cruel.

There is an alarming tendency in the U.S. renal community to be paternalistic. Oh no, children—there is a risk of infection if we let you use this technique! No, no, no! (Slaps hand.) Mustn’t risk that. But, adults make choices, based on a variety of factors, including legitimate fears of needles the size of fork tines. They make choices about a lot of health behaviors, from smoking to eating fast food to taking or forgoing medications. The job of healthcare providers is to inform people of risks and what they can do to mitigate them, then empower them to make choices. We may not always agree with their choices, but they are theirs to make—not ours.

The pro side of the debate did note the importance of user perspectives when it comes to very large needles, and it did find some hope that strategies could be found to mitigate at least some of the infection risk. Let’s avoid throwing out the “baby” with the bathwater and continue looking at how to obtain better outcomes from this alternative needling option.


  1. Cafazzo JA, Leonard K, Easty AC, Rossos PG, Chan CT. Patient-perceived barriers to the adoption of nocturnal home hemodialysis. Clin J Am Soc Nephrol. 2009;4:784-9
  2. Jayanti A, Foden P, Wearden A, Morris J, Brenchley P, Mitra S, on behalf of the BASIC-HHD study group. Self-cannulation for haemodialysis: Patient attributes, clinical correlates, and self-cannulation predilection models. PLOS One. 2015;May 19 10(5):e0125606. Doi: 10.1371/journal.pone.0125606
  3. Pipkin M, Eggers PW, Larive B, Rocco MV, Stokes JB, Suri RS, Lockridge RS for the Frequent Hemodialysis Network Trial Group. Recruitment and training for home hemodialysis: Experience and lessons from the nocturnal dialysis trial. Clin J Am Soc Nephrol. 2010;5:1614-20

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Comments

  • Steve

    May 14, 1:36 AM

    My wife has been doing HHD since 2014 with myself doing the cannulation, standard 15ga blunt needles. While she's had multiple (almost annual) fistula grams with intervention for minor stenosis, the ONLY other issues were an infiltration by the staff during our initial training for HHD, and a ruptured aneurism created by a doctor during an angioplasty for stenosis. It was for these reasons that she's on her second set of buttonholes. Otherwise, her AVF is working remarkably well and never one sign of infection. Proper aseptic technique and continuing education go a long way to prevent issues.

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    • Dori

      May 16, 8:30 AM

      Absolutely. Fistulas are at so much more risk when a parade of different staff come at them with needles than when there is a consistent cannulator.

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  • Colin Mackay

    Apr 15, 11:06 AM

    Dori, every time I read anything by yourself or Dr Agar I thank goodness that you both feel so passionately about the issues we face every day. I thank you both.
    WRT to Dr Agars comments regarding mupirocin: I have enjoyed much better outcomes since i started using it. Every time i remove a needle, I use it and i would vigorously argue that anyone who does dialysis, regardless of what type and where, should use it.

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    • Dori

      May 16, 8:28 AM

      Thank you for the very kind words, Colin. Mupirocin has been proven effective to protect PD catheters from infection. One would think that someone would be looking at it for buttonholes, but I don't know if this has happened. I'm glad it's working for you!

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    • John agar

      Apr 15, 6:28 PM

      Thanks for emphasising this aspect of my blog comment, Colin, as I think it is a very important one. We routinely advise mupirocin, and think it should be part of the BH @ home protocol. And, thanks for you vote of support for our efforts to educate and discuss ... it can sometimes seem a lonely and under-populated space.

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  • Gale Schulke

    Apr 15, 10:23 AM

    Of course I have to weigh in. I have patients who do both. My Afro American pts don't use buttonholes because they scar up so badly. Dr. Agar, have you any data on pts who keloid? Anyway, they tend to do the ladder technique simply because over time the scar tissue is so dense that BH do not work. We use gent cream or mupiricin cream depending upon MD order. My own pts weigh in that they would never go back to in center just because of the needles. But, as Dr. Agar states, BH are not for everyone.
    I would be VERY interested in the flexible angio type needles for nocturnal. I wonder why they are not offered in the US? It seems it would be a great solution to infiltration.

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    • John agar

      Apr 15, 6:40 PM

      Gayle, my understanding is that keloid formation is several times more common (one report from Michigan says 7 x) in African Americans than in Caucasians. To be honest, I can't think of a keloids scar in an AVF here, so I have no personal experience with that, or of that. Nor do we have a large indigenous aboriginal (first peoples) population in my city or region to draw comparisons from. Finally, nor is it a topic/issue that I can recall being raised by renal units in our north where indigenous dialysis patients abound. Now that you raise it though, I will ask around. But, yes, I can imagine that a keloid track would be an impossible track, and that laddering would be essential in this cicumstance. As for plastic cannulae, we use them here and like them very much and our nursing team recently published our early experience in a vascular access journal.

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  • John agar

    Apr 14, 6:14 PM

    I feel like Dr Dolittle’s pushmi-pullyu on this issue for part of me agrees with the authors of the ‘con’ argument … all of whom I know well and utterly respect … yet I still have a firm foot in the buttonhole (BH) camp – for some!

    I believe that they ARE right that the medical literature is ‘mixed’ – at best - on the safety and other purported benefits of the BH – and for all the reasons they state. Further, some absolutely stellar services (including some of those of some of the authors) were ‘burned’ early and badly by some really nasty infective episodes of endocarditis and other issues clearly to do with using BH … and this has coloured their view and solidified their antagonism to the BH technique. I respect that, and we have had similar experiences – though maybe not quite so badly.

    However, we have chosen, in my own unit, to persist with BH … but only in some patients – and by no means all – with about 40% of our 50-odd current home NHD patients using BH and about 60% using laddering.

    Why? Well I think the whole BH debate is a minefield of likely clinical contributors – both ‘pro’ and ‘con’.

    One of the centres to drop the BH here in Australia is in the tropical belt – its heat is sweaty, steamy, and moist. Fungus grows on buildings there! In my own city of Geelong, the heat is crackling dry, with little or no moisture in the air. And, I think simply ambient differences like this MIGHT matter, though I have no study proof to say so, nor do I know how that kind of information might be studied and gathered. But … needles that ‘dwell’ for longer dialysis runs, or do so more frequently (or both), in recurrent fibrous tracts through sweaty skin – especially if stabilisation-taping is loose (or works loose) – may be more ‘at risk’ of local infection, or providing surface to blood conduits for bugs than are needles in dry skin.

    Many of our home HD patients are elderly. They have paper-thin skin and little substantive subcutaneous tissue … and this may matter too, as this may influence the quality of the track … and, potentially, its healing capacity.

    We are now trying to ‘pick’ between patients for BH and ladder. We try to decide what skin type (and skill level) may lead to the ‘holding’ of a button versus those where skin type or patients skill level (or even just a feeling in the water) might suggest a ladder approach would be better.

    Do we have ANY hard evidence, and serial trial data on this? … NO! … and it is all rather ad hoc … so this response simply notes our own ‘experience’, and is not trial proof.

    We also use mupirocin, though I personally liked the idea of, the thought of - and the early outcomes with - Medi-Honey. But the patients ‘rebelled’ as they found it too sticky. The Canadians showed (and published) several years ago that there was a marked drop in infection rates (and risk) when using mupirocin and we certainly now use it here, too, for our BH’s.

    I also think we have been lax in working with our skin colleagues to document the skin types of our patients and there are several … from oily to dry, high pigment to low pigment etc … though it is very hard to get away from the cosmetic company pitch when seeking additional information, most of it being about cosmetics rather than documenting the science around the various fatty oils and secretions of the different skin types. IgE availability and other skin-defence proteins and substances may actually matter a lot in this debate … yet we know squat!

    I also think that unit ‘devotee’ status matters. Teaching and technique matters. It matters a lot! The skill levels of staff matters. BH cannot/should not/must not be taught by any Tom, Dick or Harry. That is a recipe for failure. The teacher must be full-bottle on technique and care.

    I fear that this whole BH debate risks sending two polarising messages … it risks sending a message that BH is "Good to Go” for all home patients … and THAT is a message I don’t believe is prudent … the wiser man inside me doesn’t think that is necessarily true.on the other hand, nor do I believe that the BH is a poor technique or choice … for the right arm, the right skin, the right patient. That is a message I think denies access to a good needling option, when chosen correctly.

    Unlike some who have completely reverted to the ladder technique, we have not. But, we are now quite careful (we think) in our selection process. But, what is NOT known is how to properly select. We are getting a feel for this, but if you asked me to lay down rules … I couldn’t. It all seems to devolve back to 'a feeling in the water’, a gut sense … and I know that is NOT a good premise to practice medicine from!

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    • Dori

      Apr 15, 8:30 AM

      Oh, I don't know. Medicine has always been both an a science and an art, and the art piece has been resoundingly underemphasized of late. That's why your piece on COMPASSIONATE dialysis was so important. A gut sense probably means you are taking in data about skin texture, etc., that you can't yet quantify, but that is nonetheless important...

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      • John agar

        Apr 15, 6:23 PM

        On reflection, your comment that maybe a gut feeling (or sense) about what may or not be right IS the lost 'art' of medicine may be the truth of it, but sadly, it probably would not be accepted as an adequate defence: 'Your honour .. I just had this gut feeling that ..'

        That said, I am glad you saw my previous weeks' blog on Compassionate Dialysis' in that light ... for it was just the backlighting that I had hope might be picked up and understood.

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  • Henning Sondergaard

    Apr 14, 5:35 PM

    Excellent post, Dori!

    I agree with virtually everything you say. It's time we teach those people that there are lives to be lived outside of their labs. Lives inhabited by real people and not numbers on an excel sheet to be manipulated by flawed statistics.

    I do have one caveat, though. When you ask: "Was this query science?" And "Is the plural of anecdote data?" and you answer "No" to both, it shows me you have hung out with doctors for too long. It may not be natural science to query in such a manner but in many other life sciences (like sociology and anthropology etc. ) that's the way SCIENCE is done. To blindly believe that RCT's is better science than speaking to REAL people or doing a number of in-depth intervews is ridiculous. That doctors will think so only shows they never have entered the 20th century (forget about the 21st here)

    In conclusion I wanna say RCT's is good science in some instances. Qualitative data is good in others. But to exclude one method and call it non-science is doing a disfavor to the scientific community.

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    • Dori

      Apr 15, 8:33 AM

      I'm all for collecting user impressions of techniques, but they would be more anthropological than statistical. I probably should have said, "was this a query a randomized controlled trial?" instead. So, I think you have a good point. As usual, we are in violent agreement, Henning! :-)

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