Problems with Buttonhole Cannulation

Hi am a dialysis staff member very interested in buttonhole, have done a lot of reading and been to seminars about it.
we have patients using the technique but some of them have trouble and I wanted help from the real experts on some ways to assist

  1. some patients have lots of trouble placing the blunt needle even if it’s been months after the buttonhole track has been developed?
    the sharp needle goes into place instantly, but the blunt bounces off the wall, we try twisting (drilling down) with pressure behind the needle but it won’t go, tried pulling back and repositioning,nothing… this is the same cannulator each time (the patient) how can I guide them?

  2. some patients it takes a long time for the blunt needle to go into place
    it’s supposed to be a faster needle placement, some have to site and hold the blunt needle in the hole for a few minutes seems like before it goes into place?

  3. scab removal is done very throuogh, don’t see this is the problem

  4. some patients heal very quickly - can hardly see the spot and not much scab forms even if they have been sticking for several weeks/months??

I have some questions:
Are your dialyzors going daily or three times a week?

Are they occluding their fistulas at all when they cannulate?

Are they starting at a steeper angle ~25degrees before adjusting to a more acute angle to thread into the fistula?

How many people are using this method? Are any of your dialyzors having success with the blunts?

Ah. Look - I’ve been on Home Haemo since Nov’05, after over 3 months in the ‘training unit’. I still have trouble cannulating, from time-to-time. Including night-before-last. Arterial blunt in…no worries. Venous?..several blunts…then a sharp. Even the sharp wasn’t too interested and by this time, my arm was so sore, there was no way I was going to get a decent night…so I eventually gave in, chucked TEN cannulas in the bin. Came back next morning: 2 blunts straight in. Don’t ask me why, it just happens now & then. The’ luxury’ of Home Haemo is being able to defer a treatment for hours/to next day, so I always (touch wood! :slight_smile: ) get around it that way.
IN-center I’ve had them dig like miners to get a blunt in & ended up doing the session with a very sore arm. I made my arm a little sore yesterday, having to dig just a little to get the venous in. But it was manageable. Was on for 6 hours, watching Wimbledon (overnight I would’ve done 8-9 hours).

I’ve found there are times when for no discernable reason, the tunnel at the vein wall has gotten tough or somehow scarred/healed from one day to the next. The dull needle goes in through the tunnel fine until it hits the vein wall, and then it’s no go, and no amount of twirling the needle will make it go in. When that happens, after fiddling with it a few minutes, I just switch to a sharp.

Most problems though are caused by scraping the tunnel wall too much. The needle is in that time, but the next time, it won’t go in due to blood and scar tissue.

Another fairly simple problem is that we think we are putting the needle into the hole at the exact entry point, but we’re missing it a bit. This might be because of stubborn scab that’s left just under the skin and the needle is being deflected just slightly, or being slightly off angle.

Anyway, don’t sweat it. This happens to everyone despite the most care and experience with buttonholes. That’s just the nature of the beast.

Many on this forum, and also documents about buttonholing you can find on the web, talk about going in at a higher angle and then leveling off. I can tell you that this is NOT a universal method with buttonholes. I don’t do that, but it depends on the way the vein is. However, if you do level off, my understanding is that you level off once the needle is in the vein, not in tissue, otherwise, you get a buttonhole tunnel that has two directions, and it becomes very hard to hit that leveling off point just right every time.


I have trouble too, and its been almost every time lately. I think my fistula has actually moved, as I now have to go in at a slightly different angle to what I used to. It takes me a few goes sometimes. I have also noticed it is easier if I dont use the torniquet. My fistula is quite developed and hard, so the torniquet really isnt needed anymore. If you have trouble getting a blunt in, just get a new one and try again. It can take me up to 5 times to get one in. I would only use a sharp as a last resort, as they can damage the buttonhole. As bear said, the beauty of nocturnal dialysis is, you can wait until the next night to dialyse if you are really having trouble. This has happened to me a fair few times and I usually go into emergency and get them to check my bloods so I know I am safe to skip treatment for the night.


It’s a fact that the fistula and buttonhole can “move” over time. When we’re getting better dialysis, we eat better, we may exercise more, and so we develop more muscle, maybe more fat. As a result of this, the buttonhole and the vein may actually move in relation to each other. This is exactly what happened to one of my buttonholes. Same place, but gradually, the needle was getting more and more towards the side of the vein, and eventually it was right on the vein wall. We had to make a new buttonhole. I’m told that this does happen, and I’m not the first patient in my home hemo program it has happened to.


But shouldn’t a buttonhole last longer then yours has?

There are lots of “shoulds” that don’t necessarily hold up in the real world. I see it not as the buttonhole necessarily lasting longer (although they do last longer for most people, I would think), but as buttonholes allowing the fistula to last longer because they don’t gradually form an aneurysm.

You should see how fast an unused buttonhole disappears without a trace. It’s virtually invisible after a couple of weeks. So, that’s got to say something positive about buttonholes not damaging the fistula as much. If I had been using the stepladder method with sharps over the past year and a half in the same area, I would probably have significant scarring there by now.


My fistula is bulged into an aneurysm…it was difficult making a decision where to place the buttonholes and one spot I used was a bad spot and I had to look for a new spot…the best spots I found were the sides away from the scarred skin…the point is to look for thicker fistula skin and not the scarred thin skin caused by sharps…so far I have 2 succesul sets of buttonholes…and ya, I needed alot of patience to jump start these babies… :stuck_out_tongue:


so far I have 2 succesul sets of buttonholes…and ya, I needed alot of patience to jump start these babies…

LOL! Still don’t know what is best , one set or two. Do those of you who have two sets, alternate between the sets? Do any of the bh’s ever close off since they are alternated?

I only have one set of buttonholes because I do alternate nights mostly, I think 2 sets would not get enough use. My fistula is still quite small and you can only really notice it at the wrist where the op was done apart from the 2 vampire bite marks where the buttonholes are. I do worry about having to use a sharp somewhere else as I haven’t done that in about 7 months. I hated those local needles!

Its up to you really, I use two sets and alternate between them…helps me preventing irritation, redness, and soarness…also gives time for each side to scab correctly…everyone is different…I tend to scab longer while I know other people tend to scab quickly…I guess its a matter of preference or convenience…for example, if you have a hard time getting a buttonhole on one of the sets you can just use one of the other sets…

How many of you have two sets of bh’s?

My fistula has moved slowly over time, and I think I may need to make a new arterial site, as its becoming increasingly frustrating to cannulate. The needle goes in ok, but it takes a few goes before I can get it into the vein. Im going incentre this week, so I’ll discuss it with the nurses.
I only have one set of buttonholes. I use to have 2 venous, but I found by the time I alternated, the other hole was starting to close up, which made it harder to cannulate. The doctors are fine with us having only one set now, but they do change their minds alot :slight_smile:

I’ve always had just the one set of buttonholes. I don’t want to “use up” any more potential needle sites on my fistula until I really have to. In the home hemo program here, everyone had only two buttonholes until recently, but now, some have 3. Having 3 of them allows them to alternate, but it’s less trouble than 4. I don’t want that for myself though, because as I said, I’m already running out of usable real estate on my fistula, and to be honest, I find that managing 2 buttonholes is more than enough for me. I wouldn’t want more.

I remember back when I did my nursing training I helped hook up a lady who had a fistula in her leg. They were using the ladder method and the poor thing had holes everywhere. There wasnt much untouched area to choose from. That was enough to convince me that buttonholes are better.


In the home hemo program here, everyone had only two buttonholes until recently, but now, some have 3. Having 3 of them allows them to alternate, but it’s less trouble than 4.

Where is the 3rd bh located?

Where the 3rd buttonhole is located depends on each person. Ideally, you would have them spaced evenly so that the first 1 and 2 can be used as arterial, and 2 and 3 can be used as venous. It doesnt matter which hole you use, as long as the arterial is below the venous. You cant have them too close together though, or your blood will recirculate and you wont be getting adequate dialysis, if any at all. I think the ideal is 2 finger width in between holes.