1. 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

2. 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!

3. 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!!!!!

4. Puncture techniques Rope ladder Regional Buttonhole
Service de néphrologie
Puncture techniques
Rope ladder
Regional
Buttonhole

5. Service de néphrologie
Rope ladder puncture

6. 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

7. Service de néphrologie

8. Results of the Cox model with primary outcome vascular access survival
Service de néphrologie
Parisotto et al.

9. Establishing Tunnel Track
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Establishing Tunnel Track
Standard procedure
Biohole procedure
Catheter

10. BioHole Buttonhole Device*
Service de néphrologie
BioHole Buttonhole Device*
plug
Support unit
Support unit
plug

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14. 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

15. Removal of scabs
Service de néphrologie

16. Service de néphrologie
Can we insert the image so a title can be added for the scab removal?

17. Soaking of scabs Saline Alcohol gel Emla Chlorhexidine creme
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Soaking of scabs
Saline
Alcohol gel
Emla
Chlorhexidine creme
Disinfecting Soap ……

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23. Service de néphrologie
Some key points
Tourniquet?
Trampoline effect!

24. 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

25. Touch Cannulation
Service de néphrologie

26. Touch Cannulation
Service de néphrologie

27. Cannulation challenges
Service de néphrologie
DEEP / UNCANNULATABLE
BUTTONHOLE IMPLEMENTATION

28. 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

29. Vwing Applications Service de néphrologie DEEP AVF
NON-TRANSPOSED BASILIC
SHORT SEGMENT AVF
AVOID AREAS OF
ANEURYSM OR DAMAGE
SELF CANNULATION
BUTTONHOLE CANNULATION

30. Service de néphrologie
Different sizes

31. 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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33. 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 – Rates estimated from clinical trial reports and post-market surveillance
Jan 31, 2014

34. Blunt ”double lumen” needle
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Blunt ”double lumen” needle

35. Blunt ”double lumen” needle
Service de néphrologie
Blunt ”double lumen” needle
18 G
14 G

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37. 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　

38. 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.

39. 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

40. 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

41. Service de néphrologie
Immediately after we disinfect the buttonhole entry site, we apply an anti-microbial film dressing to the site.

42. The anti-microbial film dressing is removed after 24 hours
Service de néphrologie
The anti-microbial film dressing is removed after 24 hours

43. Results of moist-healing application to buttonhole entry site
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Results of moist-healing application to buttonhole entry site

44. Scab removal during bathing
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Scab removal during bathing
towel
Stratum corneum

45. ＜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

46. 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

47. 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

48. Population and events Inclusion criteria Events of interest
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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

49. 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)

50. 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

51. 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

52. New measures after first infection
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New measures after first infection
New tunnel tracks
Topical Mupirocin

53. 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

54. Thank you for your attention!
Service de néphrologie
Thank you for your attention!
Service de néphrologie