The technique of placement of AV fistula or graft should take into account factors to enable self-cannulation such handedness, accessible location in the arm and patient preferences. Ease of access to the VA, choice of the dominant arm for AVF placement and full maturation are key to successful self use. In order to achive this often 2 stage procedures for superficialisation, refashioning and accessory vein ligation may need to be performed to enhance maturation and facilitate self-cannulation. These are some of the dominant access-related issues to consider for HHD patients in the creation phase. Many patients would prefer to avoid self-needling via use of a catheter, but where possible, all patients should be encouraged to consider definite access options for long term HHD. The five-year survival rate in HHD is higher for patients with AVF (95%) than for patients with CVC (78%), notwithstanding the good overall access survival rates in such patients .
Patient training and re-training for VA use
Successful patient training for self-cannulation remain the ultimate goal for success in HHD. Experience from a single center shows that total training time correlates with age, but not with access type . Several useful tools, when choosing the best cannulation technique, have been suggested in a recently published study by Faratro et al. . The step-by-step cannulation training approach with an ongoing support has so far provided the best results in the Manchester HHD program . The process of access education and self-cannulation training can be time dependent and variable with a median AVF age at the start of self-cannulation as 5.5 months since full maturation . The most often used cannulation technique is sharp, and about one third of the patients use the buttonhole approach . From the patients’ experience, self-cannulation is an important aspect of gaining control over their treatment, building self-confidence and eventually the norm in HHD. Identification and understanding the barriers encountered by the patient would allow better cooperation between the patient and medical team in order to achieve independence with self-cannulation . Where the final step of self cannulation is not achieved, patients can be considered for self care HD in a limited care centre with access to cannulation support. Several strategies have been described to overcome the possible barriers to fear of self cannulation, such as using the hierarchical approach, exercising patience, using dull needles, peer modeling, measuring anxiety and applying relaxation techniques and topical analgesics . The ongoing debate on the relative merits of buttonhole versus rope ladder cannulation technique still remains a subject of debate. The buttonhole cannulation technique has been associated with higher rates of infection, increased staff support requirements and no reduction in surgical AVF intervention compared to rope ladder in HHD patients, even though many patients personally prefer the former technique for comfort and less pain [7, 8]. Some centers have defined technical criteria for choice of these cannulation techniques in order maximise its advantages but avoid complications, including the risk of infection (Figure 2).