Establishing new button hole cannulation problems

Hi Stuart ,

I have been on home hemo for 10 yrs and am doing very well ; very fit and healthy. I had been using the same two button holes for the first nine years without problems apart from granular scarring on the skin surface, I eventually developed some stenosis , had a fistulaplasty with good results . I relocated the button holes away from the original two (one year ago) as expected I have the granular scarring so thought I would create a second set of buttons to use concurrently with the other two and alternate between the two pairs on a daily basis ( I dialyse every night for 8 hrs) as I’ve been told this will help alleviate the trauma to each hole . I am lucky that I have long straight usable lengths of fistula , however at the central forearm region where I would prefer to locate the cannulas ; the tissue above the vein is so tough that sharp cannulas struggle to go through. I tried an area about 4cm proximal to the anastomsis and the cannula went in very easily with no problems dialysing .My question is :do you have any suggestions for helping with the "tough as leather " prefered needling section and is it ok to form a button hole in the region where the thrill can be felt ie approx 4cm from the anastomosis ?
Thank you for any advice

What type of needles are you using? Medisystems ? or Harmomey

how deep is the mid forearm when you cannulated 1/4 or deeper

I am using Asahi- Kasei Medical 15g cannulas to establish the buttons and will be using Nippro 15g blunts when formed

The mid forearm is slightly greater than 1/4" before blood flashes into the cannula

ok I don,t know where you live if you are in the USA or not, but if you are get a DR orders for the Harmony buttonhole needle. and after you get them you will know why. If you can, restated your old buttohnole they are still good, and have three buttonhole sites. It is very rare one have that lenght of a fistula but you appear to have one. Have you had a problems with infections?

Thanks for the advice , I will try to scource the needles that you recommend ( I am in Australia) .Did you have any thoughts on locating a button hole in that area as mentioned ( 4cm from the anastomosis ) ? Luckily I have never had an infection .

4cm for the ansatomsis is ok watch for anyurysum