作者: 葉時孟醫師 ( Shih-Meng Yeh, MD )
前記: 久違的英文演說
因為診所病人的需求，於 5 年前和診所資深護理師一起到台南光明診所取經，觀摩學習扣眼式上針法。光明診所在這一塊的經驗非常多，李思遠醫師也給了很多實際執行面的解答和建議。
近期剛在部落格分享關於扣眼式打法的介紹，適逢台南成大醫院國際醫療中心執行衛福部肯亞醫衛合作案，辦理醫事人員來台交流訓練，預定於今日 ( 2025/10/16 ) 參訪光明診所，觀摩扣眼式上針。
李醫師來電邀請我用英文作一個介紹和簡短演說，對於久未上台，且要用非母語演說，心中開始有些忐忑。幸好現在有 chatgpt 可以幫忙潤稿，15 分鐘的演說也花了十 數小時的練習時間。
原本是「從從容容、游刃有餘的」，但可能昨晚在診所練習完，沒有關檔案拔除隨身碟，竟然早上在家中檢視演說檔案發現檔案毀損打不開。 幸好之前有寄給李醫師演說的 PDF 檔預定內容，才能「匆匆忙忙、連滾帶爬」的重新製作簡報和動畫，真的了解到一再確認是多麼重要的事。
演說完畢也和仁得診所的黃子豪醫師、肯亞來交流的護理人員作現況的交流，是獲益良多的一次經驗。
放上這次英文演說的內容，供外國來賓作為參考和記錄。
Introduction
Ladies and gentlemen, good afternoon , and welcome to Taiwan.
Let me begin by introducing myself. My name is Shih Meng Yeh, and I come from Kaohsiung, a city located even further south than Tainan.
I run a hemodialysis clinic in Kaohsiung, and in my spare time I write a blog where I share knowledge about dialysis and chronic kidney disease.
Like you, I once visited Guang Ming Clinic to learn about the buttonhole cannulation technique, with the hope of bringing its benefits to patients who truly need it.
Recently, I also shared an article on my blog about this very technique. Today, thanks to the kind invitation of Dr. Lee, I am honored to give a short presentation on this topic.
Connection since 5 years ago
At that time, I had a young patient. She had a history of type 1 diabetes and chronic kidney disease , unfortunately, during her pregnancy her kidney function rapidly declined, and she had to start long-term dialysis.
Because she was young, she cared very much about cosmetic issues. She also had an older sister in Taipei, who was also on dialysis and had received the buttonhole cannulation technique. So she asked me if there was any way I could provide the same treatment for her.
With the support and coordination of Huajiang Medical Instruments Company, in 2020, three senior nursing staff and I , visited Guang Ming Clinic to learn the buttonhole technique. After that, we were able to apply it successfully for this patient, and she has been using it smoothly up until now.
An accidental finding in 1972
At that time, Dr. Twardowski was caring for a dialysis patient with a very difficult vascular access. Because it was almost impossible to change the puncture site, the nurses had no choice but to repeatedly insert the needle in the exact same location.
Over time, they noticed something surprising: cannulation at this spot became easier and easier. The reason was that, in those days, needles were disinfected and reused. Through repeated use, the sharp needles gradually became blunt. This unintentionally reduced trauma to the tissue and allowed the needle to slide smoothly along the previously established track into the fistula.
This accidental finding inspired what we now call the buttonhole technique. In the early days, it was sometimes referred to as constant-site cannulation, because the puncture was always made at the same location.
Botton hole and ear piercing
When I explain this technique to patients, however, I often find that the example of ear piercing is even easier for them to understand. Just like an earring slides through the same hole every time, the dialysis needle follows the same established track into the fistula.
Keys steps in performing buttonhole cannulation
First, we need to establish at least two tracts. Traditionally, this was done by experienced nurses, who would use sharp needles to cannulate the same site, at the same angle and direction each time. However, since people are not machines, it is easy to deviate slightly, which often leads to multiple, inconsistent pathways.
Thus there comes the modified method with the Bio-hole. Nowadays, we use a sterile plug, called the Bio-hole. After the very first successful cannulation, this plug is inserted to prevent the tract from closing.
During the next two to four weeks, the plug is replaced at every dialysis session, which helps the tract mature properly.
Once the tract is matured, cannulation must be carried out under strict aseptic technique. A blunt needle is used, and it should glide gently along the established tract, without applying extra force.
Finally, after cannulation. We must continue to maintain aseptic handling and always focus on infection prevention.
The operation of the biohole plug
At the tail end of the plug, there is a small handle for gripping.
After needle withdrawal and hemostasis, or when replacing the plug, the handle should be held firmly by hand to carefully insert the plug into the tract.
Next, using a sterile-gloved hand or sterile forceps, press the plug in place.
Then, detach the handle from the plug. secure the plug to ensure it stays properly in position.
Aseptic preparation and cannulation
First, the patient should thoroughly wash the fistula site with soap.
The cannulating staff must then perform proper hand hygiene, put on sterile gloves, and disinfect the tract site with either 2% chlorhexidine or povidone-iodine.
It is important to allow the disinfectant to dry completely. Chlorhexidine dries more quickly, in about 30 seconds, while povidone-iodine requires a longer time, usually at least two to three minutes.
Some guidelines recommend softening the scab before removal. However, others suggest this may cause the scab to break into small fragments, which makes complete removal more difficult and increases the risk of contamination.
Once the scab is removed, the site must be disinfected again and allowed to dry.
Finally, a blunt needle should be used to gently slide along the tract, without applying extra force.
Infection prevention after decannulation
After needle withdrawal and hemostasis, it is recommended to apply the antibiotic ointment Mupirocin directly on the site and allow it to air-dry naturally.
At the end of the procedure, the staff should once again wash their hands thoroughly.
Advantages of the botoonhole cannuation technique
First, it helps to reduce pain. This is particularly beneficial for patients who previously experienced difficult cannulation, as the established tract allows the needle to follow the pathway smoothly each time. However, even with a blunt needle, patients may still feel some sensation as it passes through the subcutaneous tract.
Second, it lowers the risk of cannulation failure or subcutaneous hematoma caused by blood leakage.
Third, it reduces the risk of aneurysms formation.
And fourth, it decreases the likelihood of vascular stenosis and occlusion, which are often the result of improper or repeated sharp-needle cannulations.
Limitations and drawbacks
First, it cannot be used with synthetic grafts.
Second, on average, the infection rate is relatively higher compared with the gold standard rope ladder cannulation technique.
However, this risk can be minimized. With careful patient selection, and through strict aseptic awareness and proper cooperation between both the patient and the healthcare team, the likelihood of infection can be reduced to the lowest possible level.
Rewiew of Rope ladder cannulation
Rope Ladder Cannulation is a technique where each treatment session involves puncturing a new site along the entire length of the arteriovenous fistula.
Theres are some key points
Rotate sites systematically: A different puncture site is chosen each time.
Spacing: Sites are usually placed 0.5–1 cm apart.
Full vessel use: The whole length of the fistula is utilized to distribute wear evenly.
Rope ladder cannulation advantages and drawbacks
Lowest infection risk: No repeated use of the same hole reduces bacterial colonization.
Prevents aneurysm formation: Less localized vessel damage compared to area cannulation.
Prolongs access life: Stress is spread evenly across the vessel.
However, the drawbacks are that this technique is highly dependent on the experience and skill of the staff. It requires careful observation of the fistula’s anatomy and pathway.
In addition, it also relies on the patient’s cooperation. When new sites need to be cannulated, the procedure can be more painful.
Area/regional cannulation : introduction
In practice, the cannulation sites are often chosen close to previous successful sites, and both the central portion and the edges of the fistula may be used.
Because site selection is based on nearby previous points, and does not follow a planned rotation along the whole length of the fistula, the procedure tends to be easier and more straightforward for staff to perform.
Area/regional cannulation : drawbacks
Over time, this increases the risk of vessel wall damage and aneurysm formation.
Furthermore, tissue damage leads to fistula fibrosis and narrowing , eventually shortens fistula life span.
We all know that the Area Cannulation method should generally be avoided.
However, in real clinical practice, this situation sometimes occurs unintentionally.
For example, when dialysis staff rotate frequently, or when the vascular access has limited usable length, only a very short segment of the fistula may be used or available for puncture.
In such cases, the intended rope-ladder technique can gradually shift into an area cannulation pattern without being noticed.
Key points of bottonhole cannulation technique
To perform this method, at least two tracks need to be established. Whenever possible, the use of the Bio-hole device is recommended, as it helps the tunnel mature more consistently.
Strict aseptic preparation is essential, along with the correct use of blunt needles. After cannulation, preventing infection and site care is also a critical step.
The advantages of buttonhole cannulation include reduced pain, lower risk of subcutaneous hematoma, and less chance of aneurysm formation. For these reasons, it is often considered a useful alternative to the rope-ladder technique.
This method is especially suitable for patients with fistulas that are short in usable length, for those who are particularly concerned about needle pain and the cosmetic appearance of their fistula, and for patients performing home hemodialysis who need to self-cannulate.
