Overview of Self-Cannulation for Home Hemodialysis

Hemodialysis requires that two dialysis needles be inserted into the patient’s vascular access so that blood can flow from the body to the dialysis machine to be cleaned and then back into the body again. In-center dialysis patients generally have a nurse or patient care technician insert their dialysis needles, but home hemodialysis (HHD) patients must insert their own dialysis needles or have their care partner insert them. If the patient inserts his or her own needles, it is called self-cannulation.

People on HHD and their care partners are taught to insert the dialysis needles during the comprehensive safety and training course they go through before beginning home dialysis.

Patients who self-cannulate generally find that inserting their own dialysis needles is preferable to having someone else insert them. Many times, once patients are trained to self-cannulate, they don’t like anyone else inserting their dialysis needles.

There are two common techniques used for self-cannulation: the buttonhole technique and the rope ladder technique.

Buttonhole technique for home hemodialysis

The buttonhole technique, also known as constant site cannulation, is quickly becoming the most popular method of self-cannulation for home dialysis. With the buttonhole technique, patients insert their dialysis needles into the same spot and at the same angle every time they do dialysis. This causes a tract to form, creating a hole much like the hole in a pierced ear.

It usually takes about 10 cannulations with a sharp needle before the tract is created. Once it's established, patients can use blunt dialysis needles instead of sharp ones, which do not injure the tract and are safer. After each dialysis treatment, tiny scabs form over the buttonhole. Before the next treatment, these scabs are removed, usually with sterile tweezers, before each treatment so that the dialysis needles can be inserted with ease and less risk of infection. Most patients who self-cannulate using the buttonhole technique report that this technique is less painful, easier to do and requires less time than other self-cannulation methods.

In order to do the buttonhole technique, patients must have an arteriovenous (AV) fistula as their vascular access. A fistula is created by surgically connecting an artery to a vein in the patient’s arm or leg. Fistulas are the preferred access because they provide good blood flow, have a low risk of infection and clotting, and last longer than other types of accesses.

Performing the buttonhole technique:

  • Wash the vascular access area, rubbing a little around the scabs to loosen and remove them.
  • Disinfect the access area and remove any remaining scabs using sterile tweezers or forceps.
  • Disinfect the area again, after all scabs are removed.
  • Pull the skin taut and insert the needle into the same place, at the same angle and at the same depth each time.
  • Watch for a flashback of blood in the tube connected to the needle.
  • When you see the flashback of blood, lower the angle and continue to slide the needle into the fistula.
  • Tape the needle in place.

Rope ladder technique for home hemodialysis

The rope ladder technique is the method of cannulation most often used in dialysis clinics. With this technique, the needle insertion point is not the same every time. Instead, the needle is inserted about a half inch from the place it was inserted during the last dialysis treatment.

The rope ladder technique was created in order to lengthen the life of the fistula or graft by allowing the insertion points to heal before they are used again. Generally, people on home hemodialysis must use the rope ladder technique if they have an AV graft. If home dialysis patients have a fistula, they usually cannulate using the buttonhole technique.


There are two methods of self-cannulation for home hemodialysis patients. During the home training process, the home training nurse will teach the patient and his or her care partner how to insert the dialysis needles using either the buttonhole technique or the rope ladder technique, depending on the patient's type of vascular access and which method the patient prefers.

DaVita® Resources

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