Buttonhole vs Rope Ladder
– Can we ignore the facts?
Edwin Fong. MD. FRCPc
Mackenzie Health
The Challenge!
CSN Guidelines
Overview
#1: Infection
#2: Antibiotics
Pain
Infiltration
Aneurysms
• Looking at the available
evidence.
• In HHD patients (with AVF) that
are amenable to both
techniques.
• Is one form of cannulation
superior to the other?
CSN Guidelines 2013
CSN Guidelines
#1
Overview
– Unless topical antimicrobial
prophylaxis is used
#1: Infection
#2: Antibiotics
Pain
Infiltration
Aneurysms
• For adult ESRD on HHD with AVF
• Rope ladder > button hole
#2
• If BH used, suggest topical
mupirocin to reduce infection
• Conditional recommendations
• Very low quality evidence
Nesrallah, GE. AJKD 2013; 62(1): 187-98
CSN Guidelines 2013
• Assumptions
CSN Guidelines
Overview
#1: Infection
#2: Antibiotics
Pain
– Access
• Long enough usable segment
• Lack of aneurysmal dilatation
– Patient
• Able to self cannulate with RL
Infiltration
Aneurysms
Nesrallah, GE. AJKD 2013; 62(1): 187-98
#1
CSN Guidelines
High
Priority
Why RL > BH
• Infection
Overview
#1: Infection
#2: Antibiotics
Pain
Infiltration
Aneurysms
Lower
Priority
• Other cannulation complications
– Pain, Infiltration, Hemostasis
– Aneurysm
– Missed sticks/manipulations
• Training times
Nesrallah, GE. AJKD 2013; 62(1): 187-98
Research overview
Levels of evidence
Patient Populations
CSN Guidelines
Overview
#1: Infection
Randomized
with Placebo, Blinded, etc
Randomized
#2: Antibiotics
Prospective
Pain
Infiltration
Retrospective
Aneurysms
Anecdotal
HHD
CHD
#1
Infection (BH in HHD)
Design n
F/U
Bacteremia
(years) per year
Prosp
3
0.1
0
Doss 2008
#1:
Infection
Conclusion:
Lok
2011
Prosp
60
88
.07
Nesrallah
Infiltration
2009/2010
Retro
56
287
Lockridge
2010
Aneurysms
Verhallen 2007
Retro
75
75
Retro
33
287
CSN Guidelines
Marticorena
2009
Overview
Local infection
per year
RL in CHD
.001 Bacteremia
Per year
Retro
12 545
.07
.003
8
“Button
hole cannulation was associated with infection rates similar to
#2:
Antibiotics
Muir
2011
Retroin some
90 series”
313
.06
.06
those seen with CVCs
Van
Retro 63 64
.22
PainEpps 2010
.06
So RR 30-120
.02
.03
0
3 events
Grudzinski A. Semin in Dial 2013; 26(4): 465-475
Mustafa, RA. AJKD 2013; 62(1): 112-31
RL
Infection (CHD)
BH
Design n
Outcome
RL
BH
p
MacRae (2012)
CSN Guidelines
Chow (2011)
Rand
140 Local infection 22/1000 HD
50/1000HD
0.003
Rand
70
Local infection 1 pts
4 pts
.11
Struthers
Overview(2010)
Rand
56
Local infection 0
1
NS
#1: Infection
Chan
(2014)
Prosp
83
Bacteremia
5
0.67
Van Eps (2010)
#2: Antibiotics
Prosp
235 Bacteremia
Ludlow
Pain (2010)
Hashmi (2010)
Infiltration
Van Loon (2010)
Prosp
29
Infection
2
2
NS
Prosp
26
Infection
24
12
0.5
Prosp
145 Bacteremia
0
4
.001
Ward
(2010)
Aneurysms
Retro
31
0
3
0.02
Labriola (2011)
Retro
177 Local / Sepsis
RR 0.39
0.006
Nesrallah (2010)
Retro
56
0.005/1000HD 0.21/1000HD
NR
Bacteremia
Bacteremia
3
 Rate incidence 0.04
ratio 3.0
Chan M. Sem in Dial. 2014; 27(2) 210-6
RL
Infection (CHD)
BH
Design n
Outcome
RL
BH
p
MacRae (2012)
CSN Guidelines
Chow (2011)
Rand
140 Local infection 22/1000 HD
50/1000HD
0.003
Rand
70
Local infection 1 pts
4 pts
.11
Struthers
Overview(2010)
Rand
56
Local infection 0
1
NS
#1: Infection
Chan
(2014)
Prosp
83
Bacteremia
5
0.67
Van Eps (2010)
#2: Antibiotics
Prosp
235 Bacteremia
Ludlow
Pain (2010)
Hashmi (2010)
Infiltration
Van Loon (2010)
Prosp
29
Infection
2
2
NS
Prosp
26
Infection
24
12
0.5
Prosp
145 Bacteremia
0
4
.001
Ward
(2010)
Aneurysms
Retro
31
0
3
0.02
Labriola (2011)
Retro
177 Local / Sepsis
RR 0.39
0.006
Nesrallah (2010)
Retro
56
0.005/1000HD 0.21/1000HD
NR
Bacteremia
Bacteremia
3
 Rate incidence 0.04
ratio 3.0
Chan M. Sem in Dial. 2014; 27(2) 210-6
Interventions to  infection
CSN Guidelines
Overview
#1: Infection
#2: Antibiotics
Pain
Infiltration
Aneurysms
• Hygeine and Technique (CHD)
• Antibiotic as 1° prevention (HHD)
Educational workshop (CHD)
• Quality improvement report
CSN Guidelines
• Observational, retrospective, 177 pts
• Educational workshop for nurses
• Hygiene and BH technique
Overview
#1: Infection
Infectious
#2: Antibiotics
Events
Per
Pain
1000d
Workshop
Infiltration
Aneurysms
RL
BH
Labriola L. AJKD 2011; 57: 442-8
#2
Use of Mupirocin
• Single Centre, Retrospective
CSN Guidelines
Overview
#1: Infection
#2: Antibiotics
Pain
Infiltration
Aneurysms
– 56 Pts on NHD, BH cannulation
– Mupirocin 2% applied after HD
93 Pt years
193 Pt years
Pre
Mupirocin
Post
Mupirocin
8 episodes of SAB
~0.32 infections/
1000 AVF days
2 episodes of SAB
~0.03 infections/
1000 AVF days
OR 6.3. P 0.02
* RL patients on CHD ~ 0.005 infection/1000 AVF days
Nesrallah GE. CJASN 2010; 1047-53
RL
Pain (NHD)
BH
• 1 Retrosp. study (33 pts total)
CSN Guidelines
• 15 had anatomical problems
• 18 had frequent bad sticks, extreme
cannulating stress or a painful
cannulation procedure
Overview
#1: Infection
#2: Antibiotics
RL (Baseline)
BH 1.5-18mo P value
(mean values)
Pain
2.3
1.6
0.12
Cannulation ease
2.9
1.3
0.002
Bad sticks
0.8
0.3
0.03
Compression time
(min)
8.7
7.6
0.004
Pain
Infiltration
Aneurysms
Verhallen AM. NDT 2007; 22: 2601-4
RL
Pain (CHD)
BH
Design n
RL
BH
p
MacRae (2012)
Rand
14
0
1.2
1.5
0.57
Chow (2011)
Rand
70
0
5
0.01
Struthers (2010)
Rand
56
1
2.5
NS
Kim (2013)
Prosp
32
6/6
3/5
.001
Sukthinthai
(2012)
Prosp
21
6
1.2
NR
Pergolotti (2011)
Prosp
45
47%
NR
Pain
Castro (202010
Prosp
16
4
2
NS
Infiltration
Ludlow (2010)
Prosp
29
2.3/2.6 1.7/1.9 0.01
Hashmi (2010)
Prosp
26
Van Loon (2010)
Prosp
14
5
Figueiredo (2008)
Prosp
Verhallen (2007)
Prosp
47 3.08
2.4
0.12
Chan2.3
M. Sem1.6
in Dial. 2014;
46
NS 27(2) 210-6
CSN Guidelines
Overview
#1: Infection
#2: Antibiotics
Aneurysms
1
63%
NR
1.6
<.001
RL
Infiltration (CHD)
Design
BH
BH
n
RL
p
MacRae
CSN
Guidelines Rand
(2012)
140
436/1000HD 295/1000HD 0.03
Chow (2011) Rand
Overview
70
0 pts
4 pts
0.03
#1:
Infection
Struthers
(2010)
#2: Antibiotics
Ludlow
(2010)
Pain
Hashmi
(2010)
Infiltration
Van Loon
Aneurysms
(2010)
Rand
56
27 episode
19 episode
NR
Prosp
29
32 episode
11 episode
NS
Prosp
26
59%
12%
0.008
Prosp
145
14
2
<.0001
Chan M. Sem in Dial. 2014; 27(2) 210-6
Aneurysm
CSN Guidelines
Overview
#1: Infection
• 1 study (HHD) noted improved
cosmetic results post conversion
RL-> BH
Improved
Cosmetic result 12
No change
Worsening
21
0
#2: Antibiotics
Pain
Infiltration
Aneurysms
• More common in RL (CHD)
– Did not develop in above study
– No standardization of aneurysmal
dilatation measurement
Van Loon, MM. NDT 2010; 25(1): 225-30
Marticorena RM. Hemodial Int 2006; 10(2): 193-200
Verhallen AM. NDT 2007; 22: 2601-4
Other outcomes (HHD)
CSN Guidelines
Overview
#1: Infection
#2: Antibiotics
Pain
• Low # of Access related
hospitalizations
– (0.01/Access year)
• No Permanent access
abandonment
• No deaths
Infiltration
Aneurysms
Lok CE. ASN Meeting (Abstract) 2011
Nesrallah GE. CJASN 2010; 5: 1047-53
RL
Interventions (CHD)
BH
CSN Guidelines
Design n
Outcome
RL
BH
p
Chan (2014)
Overview
Prosp
83
Interventio
n
1.5 /pt
2.5/pt
0.07
Eps (2010)
#1:Van
Infection
Prosp
23
5
Nonseptic
IRR 0.48
0.12
(2010)
#2:Ludlow
Antibiotics
Prosp
29
Balloon
13
1
NS
Van Loon
Pain(2010)
Prosp
14
5
Interventio
n
0.8 /pt/yr
0.2/pt/yr
0.001
Ward (2010)
Infiltration
Retro
53
Balloon
10
3
0.008
Aneurysms
Chan M. Sem in Dial. 2014; 27(2) 210-6
Summary (1)
CSN Guidelines
#1
Overview
– Unless topical antimicrobial
prophylaxis is used
#1: Infection
#2: Antibiotics
Pain
Infiltration
Aneurysms
• For adult ESRD on HHD with AVF
• Rope ladder > button hole
#2
• If BH used, suggest topical
mupirocin to reduce infection
• Conditional recommendations
• Very low quality evidence
Nesrallah, GE. AJKD 2013; 62(1): 187-98
Summary (2)
CSN Guidelines
Overview
#1: Infection
#2: Antibiotics
Pain
Infiltration
Aneurysms
• BH appears to have increased
infection risk (HHD)
– Mupirocin may be able to reduce
infectious risk
• Pain may not be so much more in
RL c/w BH
• Other outcomes tend to favour
BH