Pro: Buttonhole cannulation of arteriovenous fistulae.

Arteriovenous fistulae remain the access of choice for most hemodialysis patients. However, several factors limit their uptake and long-term patency, resulting in suboptimal prevalent rates in many high-income countries. Patients place considerable value on the avoidance of vascular access complications, pain and disfigurement. The approach to cannulation is a modifiable practice that could improve patient-important outcomes, with buttonhole needling offering some theoretical advantages over the standard rope-ladder and area methods. In this narrative review, we summarize key findings of studies reporting the benefits and risks associated with the buttonhole method, highlighting methodological limitations as well as recent refinements to the technique that may represent potential opportunities for reducing infection risk. We highlight the need for greater certainty surrounding the potential benefits of the buttonhole cannulation technique and propose some directions for future research.