Commentary on: “Multiple Single Cannulation Technique of Arteriovenous Fistula: A Randomised Controlled Trial”

One of the most important renal nursing procedures is the cannulation of a vascular access (VA), a procedure that is carried out on every single dialysis treatment. VA cannulation method is still a procedure that reflects local unit practices and the skill of the individual nurse. Despite the impact needling has on VA survival and patient outcome, no universal or standardized method has been proposed for cannulation [1]. Observational data reveals a large variation in how different cannulation techniques are applied in clinical practice. Techniques such as buttonhole (BH), rope ladder (RL), and area cannulation (AC) are often applied in different ways, resulting in different results, which confounds interpretation of the available evidence [2]. For example, in several randomized controlled trials (RCT) [3-5] comparing RL and BH cannulation techniques, researchers described the implementation of BH in some detail but did not define how they implemented RL. What is known is that RL consists of using the entire length of the available vessel through progressive rotation with equal distribution of the cannulation sites at each dialysis session, following a diagram showing the characteristics of each individual arteriovenous fistula (AVF) [6]. BH technique requires different skills from RL, as the AVF needs to be repeatedly cannulated at exactly the same site, using the same insertion angle and the same depth of penetration every time. The available literature does not currently recommend the routine use of BH in all AVF, due to the high risk of infection, but BH may be appropriate for patients with a short cannulation segment [7]. Cannulators using AC also create new puncture sites each time, but with all sites placed in the same area, one rarely larger than 2–3 cm in diameter. The different cannulation techniques (CT) have been investigated, with guidelines stating AC should not be used because of the increased risk of complications such as aneurysms and hemorrhage [8]. VA CT have not seen any development in recent years and in the most recently updated KDOQI [9] guidelines state that rigorous studies assessing cannulation practices to achieve zero complications are necessary. To answer this challenge, a new approach to fistula cannulation with apparent benefits for patients has been used since 2013, the Multiple Single cannulation Technique (MuST) [6,10].