A comparison of the buttonhole and rope-ladder AVF cannulation techniques and infection rates within the SCOPE collaborative

Pediatr Nephrol. 2021 Dec;36(12):3915-3921. doi: 10.1007/s00467-021-05137-1. Epub 2021 Jun 11.


Background: Studies regarding hemodialysis (HD) arteriovenous fistula (AVF) cannulation in adults indicate a higher risk of infection with the buttonhole (BH) technique compared to the rope-ladder (RL) technique. Pediatric data on this issue is sparse.

Methods: We compared infection rates within the Standardizing Care to Improve Outcomes in Pediatric End stage kidney disease (SCOPE) centers performing BH cannulation versus RL cannulation of AVF. Generalized linear mixed modeling was used to assess differences in access-related blood stream infection (BSI) and access site infection (ASI) rates between the centers.

Results: Data was available from 211 AVF enrollments among 210 children. There were 61 AVF enrollments at 6 BH centers and 150 enrollments at 13 RL centers. Demographics were similar between the two groups. There were 12 total infections in 3383 patient months. BH centers had 3 infections (0 BSI, 3 ASI) and RL centers had 9 infections (5 BSI, 3 ASI). Mean [95% confidence interval] infection rates per 1000 patient months were not different between BH and RL centers (BH: 3.1 [0.6,15.6], RL: 3.2 [1.3,9.4], p = 0.947). A survey was also completed by the BH centers to describe their BH practices. The BH procedure at the majority of sites was characterized by a small patient/nurse ratio and strict antiseptic protocols.

Conclusions: This data provides evidence of a low BSI rate associated with BH cannulation in pediatric HD patients. Further studies are needed to better delineate the differences in the pediatric and adult experience with the BH cannulation technique.

Keywords: Arteriovenous fistula,; Buttonhole,; Cannula,; Children,; Hemodialysis,; Infection; Rope-ladder,.

Publication types

  • Comparative Study

MeSH terms

  • Arteriovenous Shunt, Surgical* / adverse effects
  • Catheter-Related Infections* / epidemiology
  • Catheterization* / adverse effects
  • Catheterization* / methods
  • Child
  • Humans
  • Kidney Failure, Chronic* / therapy
  • Renal Dialysis / adverse effects