Infectious complications associated with 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.

Infectious complications following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement report

BACKGROUND

Constant-site or buttonhole cannulation of native arteriovenous fistulas (AVFs) has gained in popularity compared with rope-ladder cannulation. However, cannulating nonhealed skin might increase the risk of (AVF-related) infectious events, as suggested by small reports.

STUDY DESIGN

Quality improvement report.

SETTING & PARTICIPANTS

All patients on in-center hemodialysis therapy using a native AVF from January 1, 2001, to June 30, 2010.

QUALITY IMPROVEMENT PLAN

Shift to buttonhole cannulation between August 2004 and January 2005. Because the infectious event rate increased after the shift, educational workshops were held in May 2008 for all nurses, with review of every step of buttonhole protocol.

OUTCOMES

Infectious events (unexplained bacteremia caused by skin bacteria and/or local AVF infection) and complicated infectious events (resulting in metastatic infection, death, or AVF surgery) were ascertained during 4 periods: (1) rope-ladder technique in all, (2) switch to buttonhole, (3) buttonhole in all before workshops, and (4) buttonhole in all after workshops.

RESULTS

177 patients (aged 70.4 ± 11.5 years) with 193 AVFs were analyzed, including 186,481 AVF-days. 57 infectious events occurred (0.31 events/1,000 AVF-days). The incidence of infectious events increased after the switch to the buttonhole method (0.17 [95% CI, 0.086-0.31], 0.11 [95% CI, 0.0014-0.63], and 0.43 [95% CI, 0.29-0.61] events/1,000 AVF-days in periods 1, 2, and 3, respectively; P = 0.003). This reached significance during only the second full year of buttonhole cannulation. During period 4, the incidence tended to decrease (0.34 events/1,000 AVF-days). Complicated infectious events (n = 12) were virtually restricted to period 3 (n = 11; 0.153 [95% CI, 0.076-0.273] events/1,000 AVF-days), with a significant decrease in period 4 (n = 1; 0.024 [95% CI, 0.001-0.118] events/1,000 AVF-days; RR for period 3 vs period 4, 6.37 [95% CI, 1.09-138.4]; P = 0.04).

LIMITATIONS

Observational partly retrospective design.

CONCLUSION

Intensive staff education regarding strict protocol for the buttonhole procedure was associated with a decrease in infectious events.