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S 18 Parallel Session

S 18 Cannulation Techniques
Saal 1, 27th September 2015, 9:00 – 10:30

Programme of the Session:

GS: Franzisca Frizen (Germany)
Are the common puncture techniques really up to date? 

O 43
Buttonhole: the choice to prevent loss of complex fistulae? Five years experience

Ruben Iglesias Sanjuan (Spain)

O 44
Will the buttonhole technique ever become the preferred cannulation method?

Jorge Melo (Portugal)

O 45
A new approach for arteriovenous fistula cannulation

Rui Miguel Sousa (Portugal)

O 46
Ultrasonography guided AVF cannulation education – Radiology & Nursing departments working in partnership

Joynalyn Barrios (Saudi Arabia)


Are the common puncture techniques really up to date?

F. Frizen1
1Depart.of, DKD Helios Wiesbaden – Germany

Introduction: Life expectance of vascular access is not only dependent of the quality of the patients vessels, the experience and surgical abilities of the vascular surgeon, but also of the puncture technique and skills of the repeated puncture. The guidelines at the moment recommend the rope ladder technique.
The “puncture drama”: Only the first half of the cannula is sharp, the second half is blunted. So the tissue is not stamped out by the cannula, but only divided and compressed. So there are 4 acts of the puncture:
1. The cannula makes a half elliptic cut.
2. The tissue around the cannula is compressed.
3. After removal of the cannula the channel is closed by a thrombus.
4. The organisation of the leads to a minimal tissue increase.                     
The increase of tissue is dependent of the number of puncture per surface unit. This leads to dilatation and aneurysmatic deformation of the puncture area as well as  to stenotic kinking at the edge of the puncture area.                    
The three common puncture techniques:
rope ladder: a regular distribution of repeated puncture over the whole length of the arterialised vein with a modest, but long distance dilatation effect areal punct.: there are mostly two puncture areas which develop aneurysms with typical boundary stenosis buttonhole:   the vein is punctured at the same site with the same direction and the same angle. The skin, subcutis and the vessels´wall form a scar tunnel, in which the needle is lead during the puncture. The plastic deformation of the vein is zero.
The different controllable plastic deformation of the shunt vein by repeated puncture was first described by G. Krönung (1984) with few clinical consequences. The uncontrolled area puncture ist the most applied technique.
The dilated puncture area can be enlarged distally and/or proximally by repeated puncture in its distal or proximal “borderline“ region.
Area puncture controlled and used correctly has some advantages in care of small calibre veins and is safe in unexperienced staff.
Plastic operation techniques
Using the repeated puncture as a plastic “operation” technique - depending on the morphology of the shunt vein - we recommend:
- Vein long and big: rope ladder or buttonhole
- Vein long and small: at the beginning area puncture, than changing to rope ladder puncture
- Vein short big or small: first rope ladder, later buttonhole possible
Stenotic area: could be enlarged by a lot of punctures and tissue increase in the stenotic area
Aneurysms: should not be punctured anymore
Conclusion: The repeated puncture of the autologous vascular access leads to morphologic changes by increase of tissue with dilatation and boundary stenosis. Neglecting the stenosis leads to progression and finally to occlusion of the access.
We demand for every vascular access a special and only for this access valid puncture concept. With this management a big vein can be preserved by rope ladder or buttonhole technique. A small vein or stenotic areas can by changed by systematic puncture in a dilating way. To declare a single puncture technique as the ideal one, neglects the potence of plastic transformation of the shunt vein by repeated puncture. Only the selected, especially to the individual morphologic condition of each vascular access adepted use of these three techniques  and the experience of the staff  allows the exploitation of the different plastic effects to optimize each shunt vein.


O 43
Buttonhole: The choice to prevent loss of complex fistulae? Five years experience

R. Iglesias1, X. Vinuesa1, C. Grau1, L. Picazo1, A. Liesa1, M. Garcia1, J. Vallespin2, J.R. Fortuño3, J. Ibeas1
1Nephrology, Parc Taulí. Hospital Universitari, Sabadell, Spainů; 2Vascular Surgery, Parc Taulí. Hospital Universitari, Sabadell, Spain; 3Interventional Radiology, Parc Taulí. Hospital Universitari, Sabadell, Spain

Background: Buttonhole technique is associated with fewer complications in relation to other canulation techniques. Recent publications throw doubt on safety in relation to local/systemic infections. There is no set systematic indication for buttonhole technique in high risk arteriovenous fistulae (AVF).
Objectives: Assess efficacy and safety of buttonhol technique with highly complex fistulae.
Methods: Pilot study inside a prospective case-control study to assess buttonhole technique in high complex fistulae.
Hospital HD unit, 150 patients.
September-2009 to December-2014.
Inclusion criteria: Prevalent patients with AVF's, including highly complex puncture accesses.
Sample: 34 patients.
Main variables: Access patency, function, tunnel maturation, complications, technique indication and end of use. Kaplan-Meier survival.
Screening: Dialysis adequacy, physical-examination and ultrasound-screening  (access and buttonhole tunnel).
Results: 47% females, 53% males. Average-age: 60y.o. Diabetes: 62%, Hypertension: 94%. AVF: Humeral 70’6%: Radial 29’4%  of which 50% in forearm. Complex puncture: 85’3%. Patients with 2 or more previous accesses: 44’1%. Survival: 6 months 80’3%, 1 year 80’3%, 2 years 72’2%, 3 years 60%. Indication: Short puncture section 76’5%, pain 11’8%, patient request 5’9%, self puncture 2’9%, aneurismatic AVF 2’9%. End of use: Event cases (4 technical difficulties, 2 pain, 1 patient request, 1 thrombosis).
AVF function: Average QB=315 ml/min, eKT/V=1’33.
Average tunneling time: Arterial:24’2 days, venous:25’9 days.
Self puncture:14’7%, 3 of them complex punctures.
Complications: Aneurisms(0), pseudo aneurisms(1), local infection(2), bacteriaemia(2), extravasation(2), PTA(1), thrombectomy(1). Conclusion/Application to practice: Buttonhole could be an elective technique indicated to avoid loss of complex VA, from ae cost and morbidity point of view.
Tunnelled ultrasound surveillance can help avoid complications of the puncture.

Disclosure: No conflict of interest declared

O 44
Will the buttonhole technique ever become the preferred cannulation method?

J. Melo1, R. Sousa1, P. Gonçalves1, S. Campos1, R. Peralta2, J. Fazendeiro Matos2
1NephroCare Viseu, Fresenius Medical Care , Viseu, Portugal; 2NephroCare Portugal, Fresenius Medical Care, Porto, Portugal

Background: Research shows inconsistent results of pain reduction using the buttonhole technique (BH) as compared to other arteriovenous fistula (AVF) cannulation techniques. Moreover, Ball (2009) reported various complications, i.e. infection, excessive bleeding, infiltration, and pain, mainly associated with incorrect scab removal or inadequate hygiene protocols. Highly-qualified nurses confirm scab removal difficulties and certain reluctance in using BH.
Objectives: To assess potential BH scale implementation constraints.
Methods: Descriptive, retrospective, quantitative, longitudinal, and exploratory study of BH use in our clinic over a period of 42 months analysing all major complications resulting from the change of the cannulation site with tunnel formed and blunt needles.
Results: 53 patients used BH corresponding to almost 50% of our AVF patients. 64% of BH patients were male, 21% diabetics, and 51% had a new AVF. Reasons for initiating BH included pain, aneurism, small venous track, and cannulation difficulties. The most common complications were puncture-site problems (78%), puncture-site infection (27%), clotting (22%), and excessive bleeding (22%). Infection signs were only observed at the puncture-site and in the tunnel track;no bacteraemia was observed. 6 patients changed cannulation site due to pain, 4 left the study (transplantation, death, AVF failure). 9 AVF patients changed cannulation technique due to infection (5) and excessive bleeding (4). In December 2014, 40 AVF patients were still using BH.
Conclusion/Application to practice: Even with strict protocols, puncture-site related complications make BH scaling impossible in terms of infection risk. BH is an excellent technique for specific AVF: Short fistulae, self-cannulating patients, patients with pain, and if other techniques are not possible.

Disclosure: No conflict of interest declared

O 45
A new approach to arteriovenous fistula cannulation

R. Sousa1, P. Goncalves1, S. Campos1, J. Melo1, B. Filipe2, R. Peralta3, J. Fazendeiro Matos3
1NephroCare Viseu, Fresenius Medical Care, Viseu, Portugal; 2NephroCare Abrantes, Fresenius Medical Care, Abrantes, Portugal; 3NephroCare Portugal, Fresenius Medical Care Portugal, Porto, Portugal

Background: There are few recommendations for cannulation and these mainly focus on needle size, direction, and insertion angle. Common practice is the use of a combination of rope ladder and area techniques. A recent European study confirmed that area cannulation is still widely used (65.8%) (Parisotto et al., 2014).
Objectives: To implement a new approach for the cannulation technique based on nursing knowledge, to reduce/eliminate the use of the area technique.
Methods: In a retrospective, quantitative, longitudinal, exploratory, descriptive field study we analysed all patients using an arteriovenous fistula (AVF) from February 2011 for a period of 45 months. The cannulation technique selection and follow-up were performed in nursing meetings.
Results: We started with 98% of AVF (n=90) cannulated with area technique. In the first year, we introduced the buttonhole technique and managed to reduce the area technique to 80%. In the next two years we reduced the area technique further by implementing a new multiple single puncture technique. In December 2013, 27 AVF (30%) used area technique, further reduced to 10% one year later. We reduced aneurismatic dilatation in 7 AVFs. The most common observed complication was multiple venous stenosis. No technique-related stenosis was observed. The infection rate was below 1 episode/1,000 days. We observed 7 cases of exit-site infection, but without bacteraemia.
Conclusion/Application to practice: Using the appropriate technique is vital for AVF preservation and risk reduction. With the implementation of this new approach and nursing know-how about vascular access cannulation, we were able to optimise the cannulation technique, reduce complications and avoid using area technique.

Disclosure: No conflict of interest declared

O 46
Ultrasonography guided AVF cannulation education – Radiology & Nursing departments working in partnership

J. Barrios1, J. Sedgewick1, S. Al Nosani2, T.W. Habhab2
1Nursing Education & Development, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia; 2Renal Unit, Nursing Affairs, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia

Background: In Saudi Arabia, inadequate management of CKD means 70% of patients arrive as crash landers requiring dialysis via central venous catheters. Access to vascular surgeons and patient refusal to consider AVF means an unacceptable high rate of CVC use. Those patients with AVF present difficulties for nurses in cannulating resulting in high rates of infiltration and haematoma formation.
This study aimed to:
1. Enhance nurse’s cannulation skills through an ultrasound guided cannulation education program in partnership with radiology staff.
2. Promote the longevity of AVF and reduce CVC use
Methods: Between April 2013-November 2014, Focus PDCA (Plan, Do, Check, Act) methodology was used as a practice development strategy. Nursing and radiology staff collaborated on a cannulation program delivered to 38 staff. The program focused on fundamentals of cannulation, vessel anatomy and ultrasonography Doppler use. Nurse’s skills were assessed in practice by the Sonographer along with nurses analytic and decision making in using ultrasonography data.
Results: Within 3 months of the study commencing, AVF access use increased monthly by an average of 10%. First time AVF cannulation rates substantially improved with nurses skills in cannulation of difficult fistulae enhanced. Patient’s satisfaction with cannulation improved with patients expressing confidence in nurse’s use of technology to improve cannulation.
Conclusion/Application to practice: Within Saudi Arabia, patient cultural beliefs mean patients continue to refuse AVF. Ultrasonography enhanced nurse’s skills in AVF cannulation. The study demonstrated the value of collaboration with radiology department in sharing specialist knowledge to enhance access care and enhance overall patient care experience.

Disclosure: No conflict of interest declared