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Comparison of cannulation techniques for haemodialysis

"Current evidence does not allow definitive conclusions as to whether buttonhole or rope ladder needling technique is superior" Fielding et al (2021).


Background: Cannulation of arteriovenous access for haemodialysis affects longevity of the access, associates with complications and affects patients’ experiences of haemodialysis. Buttonhole and rope ladder techniques were developed to reduce complications. However, studies that compare these two techniques report disparate results. This systematic review performs an in-depth exploration of RCTs, with a specific focus on cannulation as a complex intervention.

Methods: A PICO question and protocol was developed as per PRISMA-P guidance and registered on PROSPERO (CRD42018094656 The systematic review included any RCT performed on adult patients with end-stage kidney disease undergoing cannulation of arteriovenous fistulae or grafts for in-centre haemodialysis, as performed by healthcare staff. Assessment of quality of RCTs and data extraction were performed by two co-authors independently. Data were extracted on the study design, intervention and comparator and outcomes, including patency, infection and patients’ experiences.

Results: The literature search identified 241 records. Ten records met inclusion criteria, which described five different RCTs that compared buttonhole to either rope ladder or usual practice. Results were disparate, with patency and infection results varying. Pain Visual Analogue scores were the only measure used to capture patients’ experiences and results were inconclusive. All RCTs had differences and limitations in study design that could explain the disparity in results.

Conclusion: Current evidence does not allow definitive conclusions as to whether buttonhole or rope ladder needling technique is superior. Future RCTs should describe interventions and comparators with adequate detail, embed process evaluation, use standardised outcome measures and build on feasibility studies to produce definitive results.


Fielding CA, Hadfield A, White K, Waters D, James C, Buchanan H, Fluck RJ, Selby NM. A narrative systematic review of randomised controlled trials that compare cannulation techniques for haemodialysis. J Vasc Access. 2021 Jan 10:1129729820983174. doi: 10.1177/1129729820983174. Epub ahead of print. PMID: 33427013.