Hemodialysis patient survival is dependent on the availability of a reliable vascular access. In clinical practice, procedures for vascular access cannulation vary from clinic to clinic. We investigated the impact of cannulation technique on arteriovenous fistula and graft survival. Based on an April 2009 cross-sectional survey of vascular access cannulation practices in 171 dialysis units, a cohort of patients with corresponding vascular access survival information was selected for follow-up ending March 2012. Of the 10,807 patients enrolled in the original survey, access survival data were available for 7058 patients from nine countries. Of these, 90.6% had an arteriovenous fistula and 9.4% arteriovenous graft. Access needling was by area technique for 65.8%, rope-ladder for 28.2%, and buttonhole for 6%. The most common direction of puncture was antegrade with bevel up (43.1%). A Cox regression model was applied, adjusted for within-country effects, and defining as events the need for creation of a new vascular access. Area cannulation was associated with a significantly higher risk of access failure than rope-ladder or buttonhole. Retrograde direction of the arterial needle with bevel down was also associated with an increased failure risk. Patient application of pressure during cannulation appeared more favorable for vascular access longevity than not applying pressure or using a tourniquet. The higher risk of failure associated with venous pressures under 100 or over 150mmHg should open a discussion on limits currently considered acceptable. Hemodialysis patient survival is dependent on the availability of a reliable vascular access. In clinical practice, procedures for vascular access cannulation vary from clinic to clinic. We investigated the impact of cannulation technique on arteriovenous fistula and graft survival. Based on an April 2009 cross-sectional survey of vascular access cannulation practices in 171 dialysis units, a cohort of patients with corresponding vascular access survival information was selected for follow-up ending March 2012. Of the 10,807 patients enrolled in the original survey, access survival data were available for 7058 patients from nine countries. Of these, 90.6% had an arteriovenous fistula and 9.4% arteriovenous graft. Access needling was by area technique for 65.8%, rope-ladder for 28.2%, and buttonhole for 6%. The most common direction of puncture was antegrade with bevel up (43.1%). A Cox regression model was applied, adjusted for within-country effects, and defining as events the need for creation of a new vascular access. Area cannulation was associated with a significantly higher risk of access failure than rope-ladder or buttonhole. Retrograde direction of the arterial needle with bevel down was also associated with an increased failure risk. Patient application of pressure during cannulation appeared more favorable for vascular access longevity than not applying pressure or using a tourniquet. The higher risk of failure associated with venous pressures under 100 or over 150mmHg should open a discussion on limits currently considered acceptable. Vascular access (VA) has been justly described as both the lifeline and the Achilles’ heel of hemodialysis therapy, making blood purification itself possible while simultaneously often constituting a limiting factor in treatment adequacy. The ultimate quality indicator is the effect of the access on patient mortality and morbidity. In terms of patient survival, there is a preponderance of evidence for the superiority of arteriovenous fistulas (AVFs) or arteriovenous grafts over catheters and, to a lesser extent, for AVFs over arteriovenous grafts.1.Pastan S. Soucie J.M. McClellan W.M. Vascular access and increased risk of death among hemodialysis patients.Kidney Int. 2002; 62: 620-626Abstract Full Text Full Text PDF PubMed Scopus (377) Google Scholar, 2.Allon M. Daugirdas J. Depner T.A. et al.Effect of change in vascular access on patient mortality in hemodialysis patients.Am J Kidney Dis. 2006; 47: 469-477Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar, 3.Dhingra R.K. Young E.W. Hulbert-Shearon T.E. et al.Type of vascular access and mortality in US hemodialysis patients.Kidney Int. 2001; 60: 1443-1451Abstract Full Text Full Text PDF PubMed Scopus (624) Google Scholar, 4.Polkinghorne K.R. McDonald S.P. Atkins R.C. et al.Vascular access and all-cause mortality: a propensity score analysis.J Am Soc Nephrol. 2004; 15: 477-486Crossref PubMed Scopus (358) Google Scholar, 5.Xue J.L. Dahl D. Ebben J.P. et al.The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients.Am J Kidney Dis. 2003; 42: 1013-1019Abstract Full Text Full Text PDF PubMed Scopus (282) Google Scholar, 6.Bradbury B.D. Chen F. Furniss A. et al.Conversion of vascular access type among incident hemodialysis patients: description and association with mortality.Am J Kidney Dis. 2009; 53: 804-814Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Complications associated with the VA constitute the most common cause of patient hospitalization,7.Gauly A. Parisotto M.T. Skinder A. et al.Vascular access cannulation in hemodialysis patients—a survey of current practice and its relation to dialysis dose.J Vasc Access. 2011; 12: 358-364Crossref PubMed Scopus (15) Google Scholar the risk of which is particularly relevant to the type of VA.8.Ng L.J. Chen F. Pisoni R.L. et al.Hospitalization risks related to vascular access type among incident US hemodialysis patients.Nephrol Dial Transplant. 2011; 26: 3659-3666Crossref PubMed Scopus (79) Google Scholar, 9.Collins A.J. Foley R.N. Gilbertson D.T. et al.The state of chronic kidney disease, ESRD, and morbidity and mortality in the first year of dialysis.Clin J Am Soc Nephrol. 2009; 4: S5-S11Crossref PubMed Scopus (232) Google Scholar, 10.Pisoni R.L. Arrington C.J. Albert J.M. et al.Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis.Am J Kidney Dis. 2009; 53: 475-491Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar Therefore, in addition to choosing the best access type, prevention of access complications has high priority in dialysis therapy, and various official recommendations exist aiming at maintaining access patency for long-term use.11.National Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: haemodialysis adequacy, peritoneal dialysis adequacy and vascular access.Am J Kidney Dis. 2006; 48: S1-S322PubMed Google Scholar,12.UK Renal Association Vascular Access for haemodialysis: Clinical Practice Guidelines 2011.Final version. 2001; (Available at: (5 January, last accessed 5 June 2013)http://www.renal.org/Clinical/GuidelinesSection/VascularAccess.aspxGoogle Scholar These guidelines devised and published by various working groups focus primarily on aspects of VA management pertaining to the choice of VA type, timing of the access surgery, methods for monitoring of access function, and aseptic techniques. Recommendations for the cannulation procedure are fewer and chiefly focus on needle size, angle of needle insertion, direction of needle bevel (the slanted part of a needle, which creates a sharp pointed or rounded tip; see Figure 1), and rotation of needles after insertion. However, the evidence level for these limited guidelines is poor and, in practice, these aspects of VA cannulation are known to vary from clinic to clinic, mainly because of historical training approaches in the individual settings. It is widely accepted in dialysis field that the rotation of the needle influences the degree of endothelial trauma, the size of the puncture orifice, and, in turn, exposure to bacterial pathogens and bleeding time. The orientation of the bevel (up or down) has been reported to influence the degree of pain level.13.Crespo R. Influence of bevel position of the needle on puncture pain in haemodialysis.J Eur Dial Transpl Nurs Assoc. 1994; 4: 21-23Google Scholar Despite the recommendation for bevel-up cannulation of AVFs and arteriovenous grafts, bevel-down orientation of cannulation needles is performed today. The use of arterial needles with a back-eye, as recommended by the NKF KDOQI guidelines (2006),11.National Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: haemodialysis adequacy, peritoneal dialysis adequacy and vascular access.Am J Kidney Dis. 2006; 48: S1-S322PubMed Google Scholar has reduced the need for flipping or twisting the needle. In addition, the choice of needle size is not strictly specified. During the initial access use, the application of 17- or 16-G needles and low blood flow rates of 200–250ml/min are generally recommended, particularly in AVFs. In mature accesses, larger 15- or 14-G needles are required to support the higher blood flow rates of ≥350ml/min needed for high-efficiency dialysis or convective treatments. There is some concern that high blood flow may have a negative impact on access survival. Thus, the influence of needle size on access patency remains an open subject. Various other aspects of cannulation are not addressed in the guidelines, and there exist a variety of options to choose from. For example, standard double-needle cannulation involves inserting two large bore needles into the fistula or graft vessels, whereby three distinctly different methods for puncture site selection exist: area, rope-ladder, and buttonhole. Area cannulation refers to puncturing of the same general area session after session. In the rope-ladder technique, the cannulator changes the needle placement sites for each dialysis, choosing sites at a defined distance along the VA line from the previous puncture sites. In the buttonhole method of cannulation, hemodialysis needles are inserted in the exact same spot and at the same angle and depth of penetration for consecutive dialyses. The venous needle returns the blood from the extracorporeal circuit to the body and must always point in the direction of blood flow (antegrade direction). The arterial needle is used to withdraw blood from the vasculature to the extracorporeal circuit and may point either in the same direction of blood flow (i.e., antegrade direction) or in the opposite direction (i.e., retrograde direction) (Figure 2). The optimal direction of arterial access needles in fistulas and grafts remains a subject of some controversy.14.Ozmen S. Kadiroglu A.K. Ozmen C.A. et al.Does the direction of arterial needle in AV fistula cannulation affect dialysis adequacy?.Clin Nephrol. 2008; 70: 229-232Crossref PubMed Google Scholar,15.Toma S. Shinzato T. Fukui H. et al.A timesaving method to create a fixed puncture route for the buttonhole technique.Nephrol Dial Transplant. 2003; 18: 2118-2121Crossref PubMed Scopus (74) Google Scholar Whether or not to exert arm pressure at the time of cannulation, either using a tourniquet or manual pressure, is a further subject of debate, although application of a tourniquet is recommended by KDOQI.11.National Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: haemodialysis adequacy, peritoneal dialysis adequacy and vascular access.Am J Kidney Dis. 2006; 48: S1-S322PubMed Google Scholar Despite previous studies having addressed the issue of VA techniques and associated access survival, to date, there is a lack of convincing evidence supporting one particular cannulation procedure or a combination of procedures.16.Krönung G. Plastic deformation of Cimino fistula by repeated puncture.Dial Transplant. 1984; 13: 635-638Google Scholar,17.Konner K. Nonnast-Daniel B. Ritz E. The arteriovenous fistula.J Am Soc Nephrol. 2003; 14: 1669-1680Crossref PubMed Scopus (229) Google Scholar The primary aim of this study is to investigate whether diverse aspects of AVF and arteriovenous graft cannulation have an effect on access longevity and are consequentially more or less recommendable. Furthermore, as blood flow, venous pressure, and location of the access (e.g., right or left arm, distal or proximal) have been discussed in association with access patency, the these and access survival is also addressed as a G. M. H. et patency of AV J Google Scholar of the 10,807 patients enrolled for the original survey, access survival data were available for 7058 These patients in the and The was were were 90.6% had a and 9.4% had a graft. dialysis was Access location was arm for of During the were with and with was in the and needle were and for and of the In of patients were with and in of patients were with 16-G technique was area for 65.8%, rope-ladder for 28.2%, and buttonhole for of with some area technique was in as as of patients in and rope-ladder was more common in than in the study The direction of arterial puncture was antegrade for of this was the for of patients in The bevel orientation was for of the in with The practice of needle rotation after was for of with a higher in The combination arterial needle puncturing and bevel direction was antegrade with bevel by retrograde with bevel up The of the two other that antegrade and retrograde with bevel was and The with retrograde and bevel down were mainly in two countries and blood flow was In and and of patients were with blood in and in of patients were with blood Figure the of patients to the needle size, blood flow, and venous pressure association needle size, blood flow, and venous pressure is The primary (i.e., for a new VA during the follow-up was in patients The of these events were to survival a for access survival for patients are have body not not have and are to with A was also for patients with fistula distal location of the and low venous to cannulation technique, were for antegrade needle direction bevel up and application of not a survival was for higher blood flow and buttonhole technique rope-ladder and area, rotation not affect the access survival access The access survival to blood venous needle and cannulation techniques are in Figure In a a Cox regression model was for VA type, access location dialysis and and of the use of a 16-G needle was associated with a significantly higher risk of access failure with the use of a needle. patients were with the the direction of the is the that increased for needle a blood flow of as a the to as the blood flow to cannulation technique, both rope-ladder and buttonhole techniques performed significantly than the area antegrade with the bevel up as the retrograde direction of the arterial needle with bevel down is associated with a of access failure risk of other that antegrade direction with bevel down or retrograde direction with bevel were not associated with a significantly different from to venous pressure, using as the 100 and the increased to and with the of venous pressure from to to and Of venous pressures of are and were in of the In addition, a venous pressure of was associated with a significantly higher of investigate this also for blood flow and venous pressure, as as arterial and venous were of the Cox model with primary vascular and needle at the time of in a new the use of a tourniquet and not applying pressure at the time of cannulation were associated with of and and with of arm by the patient at the time of cannulation in In this study that area cannulation technique, as the most used technique in this of over was to rope-ladder and to buttonhole for of VA to the effect of needle and bevel the combination of antegrade of the arterial needle with bevel-up orientation was significantly associated with access survival than retrograde with bevel The use of larger needles to access patency, with to or The application of arm pressure by the patient at the time of cannulation had a favorable effect on access longevity with not applying pressure or using a tourniquet. pertaining to the type and location of the access and the (i.e., blood flow and venous were as there was an increased risk for access failure for grafts location right arm left arm, blood in the of and for the of a venous pressure pressures 100 and by cannulation procedures may cause of the fistula and the of and in turn, the of and impact fistula A. et of arteriovenous fistula in Nephrol. Google Scholar at the VA site cause that are by Of the three cannulation the buttonhole has the of limiting the of and because the is while the of a from the and The rope-ladder technique may have the initial of along the of the fistula with for The area puncture technique the fistula and is associated with the favorable that of the and of and Despite this and the that area cannulation has been for over two was to that this was the practice in of to the and the Clinical Practice Guidelines for Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: haemodialysis adequacy, peritoneal dialysis adequacy and vascular access.Am J Kidney Dis. 2006; 48: S1-S322PubMed Google J. B. et on Vascular Dial Transplant. 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For example, at an blood flow of the of the blood with a needle and with a needle by at Vascular Access Furthermore, the by blood have a in and M. et in from haemodialysis vascular Dial Transplant. 2009; PubMed Scopus Google B. G. et al.Effect of angle on the of flow in for haemodialysis Dial Transplant. PubMed Scopus Google Scholar fistula and graft are associated with the of the of and T. and new in the of venous and dialysis access Kidney Dis. 2009; Full Text Full Text PDF PubMed Scopus Google S. K. et of and in of hemodialysis Int. 2002; Full Text Full Text PDF PubMed Scopus Google Scholar at sites and blood flow may this B. G. et al.Effect of angle on the of flow in for haemodialysis Dial Transplant. 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Skinder A. et al.Vascular access cannulation in hemodialysis patients—a survey of current practice and its relation to dialysis dose.J Vasc Access. 2011; 12: 358-364Crossref PubMed Scopus (15) Google Scholar the of this survey, a cohort of patients was selected for follow-up to investigate VA survival. patients were on double-needle hemodialysis or during the of the survey were selected for as as a fistula or graft was used for survey data were and follow-up data were available in clinical D. J. et Clinical a different Nephrol. 2001; 14: Google Scholar was time the first access in the of a new access (i.e., as to for or as were for of or of the follow-up March on cannulation from the survey fistula type and cannulation technique, needle size, needle and bevel needle blood flow, arterial and venous pressure, use of use of and application of arm at the time of for individual patient the information was from the clinical patient and body of and the use of and In addition, the blood flow was at a level at the time of the For were and were performed using the with and a of for was In terms (e.g., bevel arterial needle direction) were defined for and were or in the Cox model on or A Cox model on these was using the to for within-country The for the Cox Am Scopus Google Scholar by the model was a of for variable were performed with We the from the dialysis participating in this for of the clinical The support by the and and is In addition, Skinder and for