title: Arterio-venous fistula buttonhole cannulation technique: a retrospective analysis of infectious complications.
abstract: BACKGROUND
  There are two main methods of accessing arterio-venous fistulas (AVFs); the 'buttonhole' and the 'rope-ladder' cannulation technique. Several small studies have hypothesized that the buttonhole technique is associated with increased rates of fistula-associated infection. This study addresses this hypothesis.
  
  
  METHODS
  A retrospective review of all patients attending a large outpatient haemodialysis clinic was performed. Data were collected on the method of cannulation, infection rates, implicated microorganisms, complications of infection and time on haemodialysis.
  
  
  RESULTS
  A total of 127 patients had received haemodialysis via an AVF: 53 via the rope-ladder technique and 74 via the buttonhole technique. Nine episodes of clinically significant bacteraemia were recorded in the buttonhole group. This equated to a rate of 0.073 bacteraemia events per 1000 AVF days. There were no episodes of bacteraemia in the rope-ladder group. Eight infections were due to methicillin-sensitive Staphylococcus aureus (MSSA); one was due to Staphylococcus epidermidis. Three patients with MSSA bacteraemia subsequently developed infective endocarditis. Five patients who developed bacteraemia events had been undergoing home haemodialysis.
  
  
  CONCLUSIONS
  This study highlights the infectious complications associated with buttonhole cannulation techniques. All organisms isolated in our cohort were known skin colonizers. The reason for the increased rates of infection is unclear. Given this high rate of often life-threatening infection, we recommend regular audit of infection rates. We currently do not recommend this technique to our patients receiving haemodialysis.
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: O'Brien
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Hong Kuan T
authors.initials: HK
authors.lastname: Kok
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Claire
authors.initials: C
authors.lastname: O'Kane
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Johanna
authors.initials: J
authors.lastname: McWilliams
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Patrick
authors.initials: P
authors.lastname: O'Kelly
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Paula
authors.initials: P
authors.lastname: Collins
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Joseph
authors.initials: J
authors.lastname: Walshe
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Colm C
authors.initials: CC
authors.lastname: Magee
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Denton
authors.affiliation: Department of Nephrology , Beaumont Hospital , Dublin , Ireland.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Conlon
keywords: AVF buttonhole technique; haemodialysis; infectious complications