title: Buttonhole versus rope-ladder cannulation of arteriovenous fistulas for hemodialysis: a systematic review.
abstract: BACKGROUND
  The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks and benefits of the buttonhole compared with the rope-ladder technique is uncertain.
  
  
  METHODS
  A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded).
  
  
  METHODS
  HD patients (both in-center conventional HD and home HD) using an AVF for vascular access.
  
  
  METHODS
  We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique.
  
  
  METHODS
  Buttonhole versus rope-ladder cannulation technique.
  
  
  RESULTS
  The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality.
  
  
  RESULTS
  Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference, -0.76 [95%CI, -1.38 to -0.15] standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 [95%CI, -0.76 to 1.43] standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections.
  
  
  CONCLUSIONS
  Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes.
  
  
  CONCLUSIONS
  Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs.
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada. Electronic address: bcw@ualberta.net.
authors.forename: Ben
authors.initials: B
authors.lastname: Wong
authors.affiliation: University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Maliha
authors.initials: M
authors.lastname: Muneer
authors.affiliation: University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Natasha
authors.initials: N
authors.lastname: Wiebe
authors.affiliation: University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Dale
authors.initials: D
authors.lastname: Storie
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Sabin
authors.initials: S
authors.lastname: Shurraw
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Neesh
authors.initials: N
authors.lastname: Pannu
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Scott
authors.initials: S
authors.lastname: Klarenbach
authors.affiliation: Western University, London, Ontario, Canada.
authors.forename: Alexa
authors.initials: A
authors.lastname: Grudzinski
authors.affiliation: Western University, London, Ontario, Canada.
authors.forename: Gihad
authors.initials: G
authors.lastname: Nesrallah
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Pauly
mesh_terms: D001164:Arteriovenous Fistula / Q000453:epidemiology / Q000628:therapy*; D055499:Catheter-Related Infections / Q000453:epidemiology / Q000517:prevention & control; D002404:Catheterization / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D064887:Observational Studies as Topic / Q000379:methods; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D006435:Renal Dialysis / Q000379:methods*
keywords: Buttonhole; access-related infection; arteriovenous fistula (AVF); cannulation technique; chronic kidney disease (CKD); end-stage renal disease (ESRD); hemodialysis (HD); needling pain; rope-ladder; systematic review; vascular access