Twardowski ZJ
Constant site (buttonhole) method of needle insertion for hemodialysis

Dial Transplant (Oct) 24:559-560 1995

The usual strategy of placing needles in AV accesses is to use the "rope ladder" approach, moving the needle puncture sites up and down the graft to avoid placing all of the sites in one or two areas. The latter weakens the access and predisposes to aneurysm formation. Twardowski describes another approach first described in Poland in the 70's; placing the needle into exactly the same tract every time "buttonhole approach". This method has been assessed in detail only for fistulas, and works best using a non- siliconized, slightly dull needle, to avoid leakage and cutting a new tract, respectively. Both needles are inserted in a downstream direction. The method has not been tried extensively in the U.S. for grafts, but the author thinks it should be tested with new thicker and stronger grafts. It may be ideal for home hemodialysis patients, as it minimizes the trauma and pain of needlesticks. (Daugirdas)

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Basic hemodialysis : Dialysis procedure: tips
Basic hemodialysis : Vascular Access: graft/fistula