Dialysis Needles, Self-Cannulation and the Buttonhole Technique

For many people on in-center hemodialysis (HD), getting the needles placed is the most high stress part of a treatment. Lack of control over who puts in your needles can be a black cloud over your treatment days. Fear of someone new putting in your needles may even keep you from traveling. But you can reduce your stress and feel less pain by putting in your own needles.

If you plan to do home HD, learning to place your needles (self-cannulation) will be part of your training. Learning that skill ahead of time can get you over a hurdle and help shorten your training time. You can learn to put in needles with your left hand if you are right handed, or vice versa. You do need to be able to see and to move your wrist, hand, and fingers.

When you learn to put in your own needles, you are literally taking control into your own hands—that's a great feeling. In this article, we'll cover why it's best to put in your own needles, getting past the fear, how to put in needles, and the buttonhole technique.

Keep your access longer

You've heard that your access is your lifeline, and it's true. Each person only has about 10 sites that can be used to make a fistula or graft for HD access. So, it's vital to keep each one as long as possible. The best way to do this is to have one, consistent person placing the needles. And the only person who goes to all of your HD treatments...is you.

Access defined

A fistula is a direct link from your own artery to your own vein—all your own tissue—so it's less likely to get infected or clotted. It is the best type of access and most likely to help you live longest. 1 A graft is a piece of artificial tubing used to link your artery and vein together. It is more likely to need hospital "tune-ups" to remove clots, and more prone to infection.

When your access is infiltrated (the needle punctures both walls of the access), blood leaks into the tissues and causes swelling, and often a painful bruise. The escaped blood can compress your access. This may cause stenosis (narrowing of the blood vessel) and/or a blood clot that could damage your access—or even cause it to fail.

When someone else puts needles in, they can only feel the outside of your access. Since your access is in your arm or leg, you can feel the inside and the outside. Plus, each person may use a different angle to put the needles in—while you would use the same angle each time.

Both of these factors give you a built-in edge that no one else has, not even a professional. You are much more likely to do a good job. Your access may last years longer if you put your own needles in (and this helps reduce your stress level). Some fistulas have lasted 30 years or more.

Getting past the fear

There's no question that it can be hard to get up the nerve to put in your own needles. But people who do it say that they must focus so hard on getting the needle in that it distracts them from the pain. So, it hurts much less, which is a plus.

* If needle pain or fear of needles is an issue for you—as it is for many—please be sure to read our article called Dialysis Needle Fear: Easing the Sting.

You can take baby steps to get used to the idea of putting in your own needles:

  1. Start by watching while someone else gets their needles put in.
  2. Next, try watching while you get your own needles—even just a glance at first, if that's all you can do. Look for a bit longer at each treatment.
  3. Hold your sites at the end of treatment if you haven't been doing that.
  4. Ask the staff if you can hold a needle to get used to how it feels in your hand.
  5. Think about using a topical cream or gel to numb the skin over your access.
  6. Ask the staff to teach you how to put your needles in.*
* Note: Some centers worry that they will be sued if they let people self-cannulate. Others say they can't allow it if they are not certified by Medicare for self-care or home dialysis. Neither of these is true. No center has ever been sued for letting patients self-cannulate. (Putting in your own needles is safer than having someone else do it.) Plus, Medicare supports self-cannulation as part of the Fistula First program to raise the numbers of people who have fistulas. No self-care or home certification is needed.

How to put in needles

You can learn how to put in needles by having a professional show you, step-by-step, what to do. It's more of an art than a science. There are few studies to guide how things are done. Each center does the steps a bit differently; it's best if you follow the steps the way your center or home training nurse prefers. Here are the basic steps:

  1. Gather your supplies. You'll need needles, gauze pads, tape (you'll tear a number of pieces to length), a tourniquet, a cleanser for your access, clean gloves, alcohol wipes, Band-aids, a sharps container (to dispose of used needles or syringes), etc. Have it all in one place, with tape pieces torn and ready to use, so things go faster. You may want to write a checklist (or your center may give you one) of all the things you need.
  2. Assess your access. Feel for the thrill (buzzing vibration) and listen for the bruit (whooshing sound) with a stethoscope. Your bruit should sound the same from one day to the next, and your thrill should feel the same. A higher pitched bruit or thrill that becomes weaker can mean a problem that needs to be fixed. Look for signs of infection, like pus, warmth, swelling, or redness. Never place a needle into an area of infection—you could spread it into your bloodstream. If you see signs (or have a fever), call your training nurse. Don't place needles into spots that are flat or bulging. Choose your sites.
  3. Wash your hands & access. Your center will teach you how to wash your wrists, hands, fingernails, and between your fingers, and to clean off your access site. Use the soap or antibacterial product they suggest. Dry your hands well with paper towels, and use a paper towel to turn off the faucet. Put on gloves.
  4. If you have a fistula, apply a tourniquet or blood pressure cuff . A tourniquet just below your armpit helps you see your access, keeps the vessel from rolling, and tightens the skin so it is easier to put the needles in. The tourniquet should not be so tight that it causes pain or makes your fingers turn blue! Never use a tourniquet during dialysis. Tourniquets are not used for grafts.
  5. Insert the needles. Your training nurse will teach you how to hold the needle and what angle to hold it at to reach your fistula or graft. In most cases, both needles will point up, toward your shoulder. 2 You'll grasp the wings of the needle and avoid touching it to anything except your cleansed skin. (If the needle touches something else, throw it out in a Sharps box and use a fresh one to avoid infection.) Touch it to your skin and slowly press forward until it is in the vessel. You may feel a small "pop" when it is in place. Some centers will have you attach a syringe to the needle with saline in it. Others will not. A "flashback" of blood in the syringe or at the hub of the needle once you hook it up will help you to see that you are in the right spot.
  6. Tape down the needles. You'll learn how to place tape to hold the needles in place. For nocturnal home HD, you'll use extra tape, a Tegaderm® bandage, or a similar dressing to hold your needles and tubing safely in place all night.
  7. Troubleshooting. If the arterial or venous pressures on the machine are high, or the needle is uncomfortable, it may be pulling against the wall of your access. Your training nurse will teach you how to gently move it to a better spot. You may need to tape a small gauze pad under it to help hold it in place at the right angle.
  8. Removing the needles after treatment. When your HD is done, you'll take off the tape, and slowly remove one needle at a time, putting pressure on the site after the needle is all the way out. (Pressing on the needle while it is coming out can cut your access). When both needles are out, you'll hold your sites until the bleeding stops, then tape them or use a Band-Aid® as you were taught.

Using the buttonhole technique

When needles are removed from your access, they leave small holes. Over time, with many treatments, those holes must be carefully managed to avoid damage. Too many needles in the same small area can cause weak spots that can "balloon" out to form aneurysms (the "lumps and bumps" you may have seen on a long-term access). In a graft, there is only one way to prevent this: rotating needle sites. But in a fistula, there are two ways: rotating needle sites or using the buttonhole technique.

The buttonhole technique is also called "constant-site cannulation." It's not a device; it's a different way of putting in the needles. Instead of rotating sites, you choose two sites (one for each needle) and use them only. At each treatment, you put the needles in exactly the same spots at exactly the same angle. In 8-10 treatments or so, scar tissue will form around the needle into a tunnel—like a pierced earring hole—at each site to guide the needles into your fistula. 3 The small holes, next to each other, look like the ones in a button.

When this happens, you use special, blunt needles that are much less likely to infiltrate or to change the track. People who use the buttonhole technique say that it is less painful than using a sharp needle at each HD treatment and when rotating needle sites. Once the tunnels are formed, it is usually quite easy to place the needles. Research shows that you are less likely to get aneurysms with the buttonhole technique. 4

To use the buttonhole technique, you:

  1. Gather your supplies.
  2. Assess your access. Look, listen, feel.
  3. Wash your hands and access.
  4. Disinfect your access site. Use the product your clinic tells you to use.
  5. Remove the scabs from the last treatment . Your clinic staff will tell you how to do this. Be sure to follow their steps, to avoid infection. Do NOT use your fingernails, or the tip of the needle you are going to use. Be sure to remove the entire scab.
  6. Disinfect your access site again. Scabs have germs in them. You want to be sure to kill any germs so you don’t push them into your bloodstream with the needle.
  7. Apply a tourniquet or blood pressure cuff.
  8. Insert the blunt needles. There should be no resistance when the needle slides down the tunnel. You will need a little pressure to push the needle through the blood vessel wall. Don’t push hard! Make sure that your arm is in the same spot as always. Call your training nurse for help if you run into a problem. Sometimes, you might need to use a sharp needle for one treatment.
  9. Tape down the needles.
  10. Troubleshoot if you need to.
  11. Remove the needles after treatment and hold your sites as you are taught.

Medisystems, which makes the blunt needles that are used for the buttonhole technique, has a helpful brochure and a video so you can see this for yourself. You can download the brochure here. or call 800-369-MEDI to order the Constant-Site Cannulation with Buttonhole® Needles video.


Putting in your own needles is a vital self-care skill that will help preserve your access so you can feel your best and have more control over your treatment. When you can put in your own needles, you always know that you have an expert cannulator close at hand. This can free you up to travel or think about doing home HD.


  1. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 60:1443-1451, 2001.
  2. Lewis C. Let's empower patients with the choice of self-cannulation! Nephrol Nurs J 32(2):225, 2005.
  3. Twardowski Z, Kubara H. Different sites versus constant sites of needle insertion into arteriovenous fistula for treatment by repeated dialysis. Dial Transplant 8:978-80, 1979.
  4. Kronung G. Plastic deformation of Cimino fistula by repeated puncture. Dial Transplant 13(10): 635-638, October 1984.