Buttonhole….a technique which is still evolving! Service de néphrologie Buttonhole….a technique which is still evolving! Tony Goovaerts Clinques Universitaires St. Luc Brussel, België
Service de néphrologie Literature (1) During the neighties almost no literature on actual puncture techniques Since buttonhole has become popular,…. many publications A lot of controversy Main concern: infections!
Service de néphrologie Literature (2) Huge differences between centres, countries, continents,….. Infection rates ranging from 0.05 (Vaux et al) tot 0.39 (Muir et al) per 1000 fistula days Poorly description of technique!!!!!
Puncture techniques Rope ladder Regional Buttonhole Service de néphrologie Puncture techniques Rope ladder Regional Buttonhole
Service de néphrologie Rope ladder puncture
Regional or area puncture Service de néphrologie Regional or area puncture Small puncture area with: Thinning of the vessel wall Aneurismal formation Stenosis Oozing Longer bleeding times after needle removal
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Results of the Cox model with primary outcome vascular access survival Service de néphrologie Parisotto et al.
Establishing Tunnel Track Service de néphrologie Establishing Tunnel Track Standard procedure Biohole procedure Catheter
BioHole Buttonhole Device* Service de néphrologie BioHole Buttonhole Device* plug Support unit Support unit plug
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Advantages of the BioHole Device Service de néphrologie Advantages of the BioHole Device No single cannulator? Faster tunnel track formation Better tunnel track formation Now available in 3 lenghts
Removal of scabs Service de néphrologie
Service de néphrologie Can we insert the image so a title can be added for the scab removal?
Soaking of scabs Saline Alcohol gel Emla Chlorhexidine creme Service de néphrologie Soaking of scabs Saline Alcohol gel Emla Chlorhexidine creme Disinfecting Soap ……
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Service de néphrologie Some key points Tourniquet? Trampoline effect!
Buttonhole Wrong Angle! Service de néphrologie Buttonhole Wrong Angle! Arm always in same position Angle has to be adjusted to be in alignment with vessel entrance Pull back needle till point reach the entrance of tunnel to redirect towards vessel entrance
Touch Cannulation Service de néphrologie
Touch Cannulation Service de néphrologie
Cannulation challenges Service de néphrologie DEEP / UNCANNULATABLE BUTTONHOLE IMPLEMENTATION
VWING VASCULAR NEEDLE GUIDE Service de néphrologie TARGET Serves as palpable target to facilitate dialysis cannulation. GUIDE Guides needle directly to vessel through same pathway every time, rapidly enabling use of blunt needles via simplified buttonhole cannulation. VWING Surgically-placed, subcutaneous vascular needle guide
Vwing Applications Service de néphrologie DEEP AVF NON-TRANSPOSED BASILIC SHORT SEGMENT AVF AVOID AREAS OF ANEURYSM OR DAMAGE SELF CANNULATION BUTTONHOLE CANNULATION
Service de néphrologie Different sizes
Self cannulation Service de néphrologie Obese patient with inaccessible flowing fistula VWING implanted – fistula accessed Quickest to self-cannulate at dedicated home hemo training unit
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COMPLICATION RATES (per patient year) VWING Clinical Use Summary Initial VWING implant has been used for over 3.6 years since June 2010 IMPLANT HISTORY Patients Devices VWING Patient Total / Implanted VWING Total 141 216 Patient Implant Days / Device Implant Days 46,7002 72,5002 Cannulations N/A 23,8002 COMPLICATION RATES (per patient year) Catheter (USRDS) AV Fistula (USRDS) VWING SAVE Study Rate1 VWING Overall Reported Rate1,2 Infection of Access 1.45 0.18 0.038 0.016 Sepsis 2.32 0.52 0.008 1 – Hospital-treated events 2 – Rates estimated from clinical trial reports and post-market surveillance Jan 31, 2014
Blunt ”double lumen” needle Service de néphrologie Blunt ”double lumen” needle
Blunt ”double lumen” needle Service de néphrologie Blunt ”double lumen” needle 18 G 14 G
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New method that enables complete removal of the scab Service de néphrologie New method that enables complete removal of the scab The7th World Congress of the International Society for Hemodialysis Takahiro Shinzato Daiko Medical Engineering Research Institute, Nagoya, Japan Shigeki Toma Toma Clinic, Okinawa, Japan
Characteristics of moist-healing method Service de néphrologie Characteristics of moist-healing method 1. Bleeding must be completely stopped. 2. The wound must be disinfected with diluted Povidone iodine 3. The wound must be kept moist.
Dilution ratio of povidone iodine solution Service de néphrologie and free iodine concentration （μg/mL） 250 200 150 free iodine concentration 100 isodine ® 50 J-iode ® fold 50 100 150 200 250 300 Matsuoka et al: The 10th peritoneal dialysis conference
bacteriocidal activity Service de néphrologie Bacteriocidal activity of povidone iodine solution is highest when commercial solution is diluted 100-fold. bacteriocidal activity original solution 50-fold dilution 100-fold dilution bacterias Staphylococcus aureus No No Yes Staphylococcus epidermidis No No Yes Enterococcus No No No E. Coli Yes Yes Yes Pseudomonas aeruginosa Yes Yes Yes Matsuoka et al: The 10th peritoneal dialysis conference
Service de néphrologie Immediately after we disinfect the buttonhole entry site, we apply an anti-microbial film dressing to the site.
The anti-microbial film dressing is removed after 24 hours Service de néphrologie The anti-microbial film dressing is removed after 24 hours
Results of moist-healing application to buttonhole entry site Service de néphrologie Results of moist-healing application to buttonhole entry site
Scab removal during bathing Service de néphrologie Scab removal during bathing towel Stratum corneum
＜at the time of next dialysis＞ Service de néphrologie ＜in bath a day before the next hemodialysis＞ ＜24 hours after application of the dressing＞ ＜at the time of next dialysis＞ ＜after hemodialysis＞ anti-microbial film dressing
Service de néphrologie Results of histological examination of thin membrane formed at the buttonhole entry site nuclei outside Stratum corneum Fibrin deposits neutrophils neutrophils inside
skin disinfected with diluted or non-diluted povidone iodine solution Service de néphrologie skin disinfected with diluted or non-diluted povidone iodine solution Skin disinfected with non-diluted solution Skin disinfected with diluted solution
Population and events Inclusion criteria Events of interest Service de néphrologie Inclusion criteria All patients dialysing in « Carpe Diem » Between 1990 and 2012 With functional AVF Events of interest Local infection Bacteremia Combined infection Buttonhole cannulation 1990 1998 2012 Rope-ladder SWITCH
Study population Characteristics Service de néphrologie 1st period 2nd period Number of patients 68 115 Number of AVF-days 57851 97911 Age (y) 45,8 (20,4) 46,9 (20,4) Men 39 (57,3) 70 (60,9) Underlying nephropathy Diabetic 1 (1,5) 9 (8,0) Glomerulonephritis 21 (31,8) 44 (39,2) Vascular 4 (6,1) 8 (7,1) Polycystic kidney disease 15 (22,7) 22 (19,6) Uropathy 3 (2,7) Chronic interstitial nephritis 17 (25,8) 13 (11,6) Other nephropathy 7 (10,6) Diabetes 2 (2,99) 11 (9,8) Transplantation before HD initiation 10 (14,7) 18 (15,8) Immunosuppressive therapy at HD initiation 14 (20,6) 24 (21,0) Values expressed as mean (IQR) or number (rate)
Incidence of infections Results Incidence of infections Service de néphrologie Infectious event 1st period 2nd period Local infection (alone) number 2 7 incidence rate (per 1000 AVF-days) 0,03 0,07 Bacteremia (alone) incidence rate 0,02 Combined local infection and bacteremia 1 4 0,04 All infections 3 13 0,05 0,13 Comparison of incidence? The calculated absolute incidence per 1000 fistula days was thus 0.05 and 0.13, respectively? The comparison test was not significant! Incidence rate expressed for 1000 AVF-days Exact Fisher test: p=0,44
Infection per patient Patient 1 Patient 2 Patient 3 Patient 4 Recurrence is thus an event only seen in the BHC period Patient 9 Patient 10 Patient 11 Patient 12 1990 1995 2000 2005 2010 2013
New measures after first infection Service de néphrologie New measures after first infection New tunnel tracks Topical Mupirocin
Conclusion Buttonhole better than area cannulation Service de néphrologie Conclusion Buttonhole better than area cannulation Rigourous aseptic technique is mandatory to prevent infections Technique is still evolving Further (multicentric studies) needed Encouraged to continue
Thank you for your attention! Service de néphrologie Thank you for your attention! Service de néphrologie