Effect of buttonhole cannulation with a polycarbonate PEG on in-center hemodialysis fistula outcomes: a randomized controlled trial

Am J Kidney Dis. 2013 Jul;62(1):81-8. doi: 10.1053/j.ajkd.2013.01.011. Epub 2013 Mar 7.


Background: Quality improvement strategies to increase and maintain the numbers of arteriovenous fistulas (AVFs) are a critical drive in enhancing the quality of care of patients receiving treatment with hemodialysis. How the AVF is needled is an important consideration in AVF survival; the ideal cannulation technique has not been established to date.

Study design: Prospective randomized single-center trial.

Setting & participants: Patients on maintenance hemodialysis therapy (N = 140).

Intervention: A 1-year intervention of buttonhole (constant site) or usual-practice (different site) cannulation.

Outcomes: Primary study outcome was AVF survival over 1 year, in which AVF failure was defined as an AVF no longer used for hemodialysis (also referred to as assisted patency). Secondary outcomes included primary patency, number of access interventions, bleeding time, infection rate, cannulation time and pain, and aneurysm formation.

Results: Demographic data were similar for both groups. The primary outcome measure of AVF survival at 1 year was statistically significantly increased in the buttonhole group (100% vs 86% with usual practice; P = 0.005, log-rank test). In the buttonhole group, there were fewer interventions (19% vs 39% in usual practice) and less existing aneurysm enlargement (23% vs 67% in usual practice). There were no bacteremia events in the buttonhole group and 2 in the usual-practice group (0.09/1,000 AVF days). There were no significant differences in bleeding times and lignocaine use between the 2 groups.

Limitations: A single-center study, lack of blinding.

Conclusions: In this study, AVF survival was significantly greater when using buttonhole cannulation. The buttonhole technique significantly decreased the need for access interventions and reduced existing aneurysm enlargement. Concerns of increased infection rates or prolonged bleeding times with the buttonhole technique were not seen in this study. The buttonhole technique should be considered the cannulation technique of choice for AVFs.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Arteriovenous Shunt, Surgical / methods*
  • Catheters, Indwelling*
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Polycarboxylate Cement* / therapeutic use
  • Polyethylene Glycols / administration & dosage*
  • Renal Dialysis / methods*
  • Treatment Outcome


  • Polycarboxylate Cement
  • polycarbonate
  • Polyethylene Glycols

Associated data

  • ISRCTN/ISRCTN27841616