Infectious complications associated to buttonhole cannulation of native arteriovenous fistulas: a 22-year follow-up

Background. Buttonhole (BH) cannulation of native arteriovenous fistulas (AVFs) appears to be associated with an increased infectious risk. We previously reported a dramatic increase in the incidence of infectious events (IE) after shift to the BH technique in an in-center hemodialysis unit, which was largely reduced after staff (re)education regarding strict respect of the procedure. We assessed the evolution over the following 12-year period in our center.Methods. In this prospective follow-up of a previous, pre [rope-ladder (RL)]-post (BH) comparison (2001-10), all in-center hemodialysis patients with a native AVF were included from 1 July 2010 to 31 December 2022. Primary and secondary outcomes were IE (unexplained bacteremia due to skin bacteria and/or local AVF infection) and complicated IE (metastatic infection, AVF surgery, death). Overall, the impact of several quality improvement strategies was tested according to the events rate over six periods: Period 1: RL in all; Period 2: switch to BH; Period 3: BH in all, before workshops; Period 4: BH in all, after workshops; Period 5: BH withdrawal in problematic AVFs; Period 6: additional procedural changes.Results. This extended observation period allowed the addition of 195 180 AVF-days to our previous report. Overall, 381 661 AVF-days (366 AVFs, 345 patients) were analysed. After an increase of the IE rate in 2012, the shift to RL in problematic AVFs during Period 5 did not have a significant impact. The incidence of IE decrease significantly during Period 6 compared with Periods 3, 4 and 5 {incidence rate ratio (IRR) 0.24 [95% confidence interval (CI) 0.09-0.52], P = .0001, IRR 0.22 (95% CI 0.09-0.47), P < .0001 and IRR 0.29 (95% CI 0.11-0.66), P = .001, respectively}, and became eventually for the first time comparable to Period 1 [IRR 0.59 (95% CI 0.21-1.62), P = .27].Conclusion. The constant observance of reinforced hygiene protocols by trained staff and central coordination succeeded in significantly mitigating the infectious risk associated with buttonhole cannulation.