Arteriovenous Fistula Survival and Needling Technique: Long-term Results From a Randomized Buttonhole Trial

• Published in: American journal of kidney diseases Vol. 63; no. 4; pp. 636 - 642
• Main Authors: MacRae, Jennifer M., MSc, MD, Ahmed, Sofia B., MSc, MD, Hemmelgarn, Brenda R., MD, PhD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.04.2014; Elsevier
• Subjects: access survival; Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Arteriovenous fistula (AVF); Arteriovenous Shunt, Surgical - adverse effects; Arteriovenous Shunt, Surgical - methods; Biological and medical sciences; buttonhole needling; cannulation; Emergency and intensive care: renal failure. Dialysis management; Female; Follow-Up Studies; Hematoma - epidemiology; Hematoma - etiology; hemodialysis access; Humans; infection; Intensive care medicine; Male; Medical sciences; Middle Aged; Nephrology; Nephrology. Urinary tract diseases; patency; Renal Dialysis; Survival Analysis; Suture Techniques; Treatment Outcome; Tremor; Vascular Patency; Venous Thrombosis - epidemiology; Venous Thrombosis - etiology; patency; access survival; infection; buttonhole needling; Arteriovenous fistula (AVF); hemodialysis access; cannulation; Nephrology; Accessibility; Hemodialysis; Cardiovascular disease; Congenital disease; Long term; Survival; Urology; Venous disease; Arterial disease; Vascular disease; Infection; Extrarenal dialysis; Randomization; Arteriovenous aneurysm; Clinical trial; Technique; Arteriovenous malformation
• ISSN: 0272-6386; 1523-6838
• DOI: 10.1053/j.ajkd.2013.09.015

Background We previously have shown that buttonhole needling is associated with a reduction in hematoma and postulated that buttonhole needling may increase long-term survival of an arteriovenous fistula (AVF). The purpose of this study was to evaluate AVF survival and complications in buttonhole versus standard needling. Study Design Long-term follow up of a randomized controlled trial in which participants were randomly assigned to standard or buttonhole needling and followed up until the AVF was abandoned or the study end date. Setting & Participants 140 long-term hemodialysis patients in Calgary, Alberta. Intervention Buttonhole needling with median time of exposure to the intervention of 13.2 (IQR, 7.8-19.4) months. Outcomes & Measurements Patients were prospectively followed up for study outcomes. Median follow-up times were 17.2 (IQR, 11.9-37.8) and 19.2 (IQR, 12.5-41.0) months for standard and buttonhole needling, respectively ( P = 0.2). The primary outcome was median access survival in months. Other outcomes included assisted and unassisted patency rates, rates of surgical and radiologic interventions, and time to abandonment (months) of buttonhole. Results Baseline characteristics were similar. The primary outcome, median access survival, was similar in both groups: 16.0 (IQR, 10.6-29.3) and 18.4 (IQR, 10.9-32.7) months for standard and buttonhole needling, respectively ( P = 0.2). There were 7 (10.1%) and 6 (8.6%) thromboses with standard and buttonhole needling, respectively ( P = 0.6). Median fistulogram rates were similar between techniques ( P = 0.2 with intention-to-treat analysis). Most patients (46 of 70) abandoned buttonhole needling by a median of 11.3 (IQR, 4.8-18.2) months. Median time to first infection for buttonhole needling was 11.1 (IQR, 4.9-30.0) months. There were no infections in standard needling of AVFs. Limitations Findings are limited to patients needled by multiple hemodialysis nurses and not applicable to self-needlers. Conclusions AVFs with buttonhole needling did not have improved survival. The lack of survival benefit and higher risk of infection should be noted when promoting buttonhole needling.