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This technique was described in 1972 by Dr Twardowski and involves the cannulation of the arterialised vein using blunt needles&#44; at the same angle and at the same site&#44; via a previously formed tunnel&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">3</span></a> Once the dialysis is completed&#44; after the corresponding haemostasia&#44; a scab is left at the puncture site which should be properly removed in the next HD session&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">4</span></a> Several studies have shown that it is possible to improve clotting times&#44; which could help to reduce pain and may also help to maintain vascular access as compared to other techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">5&#8211;8</span></a> However&#44; other studies have shown a high incidence of infections&#44; therefore its acceptance has been limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">9&#8211;12</span></a> Its application is widely established in some countries&#44; especially in some northern European countries and in the USA&#44; but not in Spain&#44; where there are only few centres that use it&#46; To our knowledge&#44; our centre is the first in the Madrid Region to use this technique regularly&#46; Here we are presenting our experience&#44; over 3 years&#44; after its instauration and the maintained used of this technique&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">From 2012 to December 2015&#44; all the patients who started the BH technique at our centre were evaluated&#46; A retrospective study was carried out to analyse the characteristics of the patients&#44; clinical evolution&#44; the expected benefits of the technique and the possible drawbacks of its implementation&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The inclusion criteria for the BH technique were patients over the age of 18 years presenting with one of the following circumstances&#58; patients with the option of home HD&#44; patients with autologous arteriovenous fistulas &#40;AVFs&#41; that are difficult to puncture or with multiple unsuccessful punctures&#44; or patients with significant pain or unable to deal with the fear for AVF puncture&#46; Also included&#44; were those who expressed an interest in the technique and had no contraindications&#46; All patients were verbally informed with additional written information if requested&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The exclusion criteria were those with a prosthetic device for vascular access or those that did not came to the unit for prolonged periods of time and were incapable of self-cannulation since it could imply that they were treated at another centre not familiar with the BH technique&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Buttonhole technique</span><p id="par0025" class="elsevierStylePara elsevierViewall">The buttonhole technique involves the creation of a subcutaneous tunnel as a permanent and invariable route of access to the AVF&#59; once it is created a blunt needle can be inserted&#46; The first puncture must be made using a conventional needle&#46; The area should be selected&#44; considering that the 2 puncture areas should be at least 6<span class="elsevierStyleHsp" style=""></span>cm apart and&#44; avoiding aneurysmal areas&#46; Once the first HD session is finished&#44; both needles are removed&#44; and the site is left to form a clot without any haemostatic dressing&#46; After the correct coagulation as been completed the area it is sterilised with aqueous chlorhexidine&#46; After leaving it for a few minutes f to have an antiseptic effect&#44; a 5<span class="elsevierStyleHsp" style=""></span>mm-long polycarbonate device&#44; similar to a peg&#44; is used at the puncture site to stabilise the tunnel &#40;BioHole<span class="elsevierStyleSup">&#174;</span> Nipro Corp&#41;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">13&#44;14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The BioHole is inserted using a sterile technique and covered with a transparent dressing&#46; The BioHole remains in place until the next session&#46; At the next session&#44; the transparent dressing is removed without removing the BioHole&#44; and it is sterilised with aqueous chlorhexidine&#44; prior to and after manipulation &#40;double asepsia&#41;&#46; Once the BioHole is removed with the aid of tweezers and using sterile technique&#44; the vascular access will be cannulated using a blunt needle once the tunnel is visible&#46; The stabilisation BioHole should be inserted in 5&#8211;6 sessions&#44; always using the same technique and by the same previously trained nurse&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Buttonhole handling technique</span><p id="par0030" class="elsevierStylePara elsevierViewall">Once the tunnel is established&#44; the puncture is made using a blunt needle&#46; The first step is to remove the scab that is formed at the access site after clotting&#46; Again using an aseptic technique&#44; and ensuring that the area is disinfected both before and after removal of the scab &#40;double asepsis&#41;&#46; Next the site is cannulated using the blunt needle&#44; following the path of the previously formed tunnel&#46; Clotting should be helped manually&#44; without using any type of haemostatic dressing&#44; in order to minimise the risks of infection and reduce the possibility of the haemostatic dressing plugging the tunnel&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Organisation of nursing staff</span><p id="par0035" class="elsevierStylePara elsevierViewall">One single nurse is responsible for creating the BH and he&#47;she will have to adjust his&#47;her work schedule until the BH is correctly formed&#46; After successful completion&#44; the rest of the staff&#44; who has been previously trained in this technique&#44; is informed of the location and peculiarities of the specific BH&#46; From then on&#44; BH punctures can be performed by any member of the nursing staff&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">The results are expressed as the mean and standard deviation&#59; the median and range are also shown when required&#46; At the start and end of the study&#44; means were compared using the Student&#39;s <span class="elsevierStyleItalic">t</span> test for parametric data&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;0&#46;05 was considered to be significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Over this 3<span class="elsevierStyleHsp" style=""></span>y period 22 patients were evaluated&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes their baseline characteristics&#46; There were 15 male and 7 female patients with a mean age of 62 years&#46; 9 patients received antiaggregation therapy and 7 were anticoagulated with acenocoumarol&#46; Mean time on HD at the start of BH was 34 months &#40;SD&#58; 34&#59; range&#58; 3&#8211;136 months&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The types of vascular access and the puncture technique prior to the BH technique are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The most common AVF was left radiocephalic AVF in 9 patients&#44; followed by left humero-cephalic AVF in 8 patients&#44; the other AVFs were&#58; 2 right radiocephalic AVFs&#44; 2 left humero-basilic AVFs and one right humero-cephalic AVF&#46; The technique of the previous puncture was the rope-ladder in 10 cases&#44; the area technique in 6 patients and in 6 other cases a combination of the area and rope-ladder techniques were used&#46; Mean time of vascular access before the technique was changed was 41 months &#40;SD&#58; 55&#59; median&#58; 26&#59; range&#58; 3&#8211;252&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Survival of the buttonhole</span><p id="par0055" class="elsevierStylePara elsevierViewall">Of the 22 BHs performed at the unit&#44; 12 continued to function as of December 2015&#46; The main cause of BH loss was kidney transplantation in 6 patients&#46; One case of BH loss was due to death&#44; caused by a cerebral haemorrhage&#44; in a diabetic patient with hypertension&#46; In one case it was due to vascular access thrombosis and in 2 cases the BH technique had to be abandoned&#46; One of those cases was due to suspected infection of the tunnel &#40;despite negative control culture&#41;&#44; as the patient was immunosuppressed&#44; within the context of a functioning liver transplant and&#44; the other case was due to difficulty in obtaining access to a very deep humero-basilic AVF as the patient was significantly obese&#46; This particular patient subsequently required superficialisation of the basilic vein&#46; At the end of the study&#44; the mean time with BH was 12 months for all patients &#40;SD&#58; 11&#59; median&#58; 9&#41;&#46; The mean BH time&#44; for those who maintained the BH technique at the end of the study&#44; was 15 months &#40;SD&#58; 11&#41;&#46; The patient who spent the longest period of time using the BH technique is currently on home HD &#40;patient 1&#41;&#46; All the other patients are undergoing a HD programme at the hospital&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Infections</span><p id="par0060" class="elsevierStylePara elsevierViewall">We did not observe any bacteraemia that we could be related to a BH infection of the during this follow-up period&#46; A distal tunnel infection was observed in patient 4&#44; which was confirmed by means of a positive culture for <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&#46; There were no systemic repercussions&#46; After oral antibiotic treatment and removal of BH from said tunnel&#44; a new tunnel was inserted&#44; which continues to be functional and in use to this date&#46; Patient 3 presented with suspected infection with serous exudate&#58; the culture was negative and the BH remained in use&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Haemostasis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Haemostasis times were analysed prior to installing the BH in all patients and at&#44; 1&#44; 6 and 12 months after regular use&#46; Mean haemostasis time prior to the BH was 18&#46;6<span class="elsevierStyleHsp" style=""></span>min &#40;SD&#58; 8&#41; and it was significantly reduced to 12&#46;2<span class="elsevierStyleHsp" style=""></span>min &#40;SD&#58; 3&#41; at month 1 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0005&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Mean haemostasis time at 6 months was 11&#46;2<span class="elsevierStyleHsp" style=""></span>min &#40;SD&#58; 2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16 patients&#41; and at 12 months it was 10&#46;9<span class="elsevierStyleHsp" style=""></span>min&#44; &#40;SD&#58; 4&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9 patients&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Self-cannulation</span><p id="par0070" class="elsevierStylePara elsevierViewall">At the beginning of the study none of the patients self-cannulated their vascular access&#46; Once the BH was installed&#44; at the end of the study&#44; 5 patients self-cannulated on a regular basis&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Pain management</span><p id="par0075" class="elsevierStylePara elsevierViewall">Surveys were conducted to assess pain&#44; in which 1 indicated no improvement and 10 indicated an absolute improvement compared to the puncture prior to the installation of the BH&#46; The mean response as to whether there had been an improvement from the previous technique was 9&#46;1&#46; The comparison of pain perception before and after installation of the BH &#40;1 &#8211; worst pain and 10 &#8211; no pain&#41; was 4&#46;7 vs&#46; 8&#46;8 respectively and significantly favouring the BH&#44; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;00001&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Other complications</span><p id="par0080" class="elsevierStylePara elsevierViewall">On 9 occasions a new BH tunnel had to be created due to the failure of the previous one&#46; On 2 occasions&#44; after receiving care at other centres&#44; in one case due to the voluntary transfer of the patient and in another case due to surgery&#46; The BH technique could be subsequently maintained after the creation of a new tunnel in all cases&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The majority of observational studies describe that with BH technique there is a reduction of pain&#44; a lower number of punctures&#44; less bruising and a reduced formation of aneurysms&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">16&#44;17</span></a> However&#44; systematic reviews focused on this technique have shown that current evidence does not support these results and that the risk of infection is greater in patients with BH&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">12&#44;18&#44;19</span></a> In spite of that&#44; the BH technique may be a valid alternative in some situations&#46; Area puncture complications are well-known and on many occasions rope-ladder punctures are difficult to achieve&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">1</span></a> We decided to include the BH technique as an additional option of puncture techniques at our centre&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The draw back of BH technique is the higher incidence of infections&#46; The rate of bacteraemia described in previous studies was 0&#46;15&#8211;0&#46;6 per 1000 patients&#47;day or 0&#46;05&#8211;0&#46;2 per patient&#47;year&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">5&#44;6&#44;20</span></a> The review conducted by Muir et al&#46; put forward evidence for this&#44; though it was conducted on a population on home HD&#44; which could mean less control of asepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a> However&#44; the Alberta group&#39;s published in 2014 more complete review&#44; covering patients on conventional HD&#44; indicating that the risk of infections was greater&#44; without a clear benefit in other respects&#46; The authors concluded that this did not exclude the use of BH in certain specific situations&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">19</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In our experience of 3 years of follow-up we have not observed any bacteraemia and we have had only one local infection confirmed by culture Similar results were described in the randomised clinical trial conducted by Vaux et al&#46;&#44; which included 70 patients on the BH technique&#46; No bacteraemia was observed during the follow-up period and only 2 infections were noted at the puncture site&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">21</span></a> In the Chan et al&#46;&#44; 2014 study&#44; found no significant differences in infection between the BH technique and the rope-ladder puncture technique &#40;bacteraemia with BH&#58; 5 &#91;11&#37;&#93; vs&#46; conventional&#58; 3 &#91;8&#37;&#93;&#59; <span class="elsevierStyleItalic">p</span>&#58; 0&#46;62&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> Double asepsis was maintained at our unit and thorough monitoring was carried out by the nursing staff as key considerations for avoiding infections&#46; Although some studies showed a potential benefit with topical mupirocin prophylaxis&#44; this was not applied routinely in our population&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">23</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Incidentally&#44; we observed a single case of thrombosis in our group&#46; Although our study was not designed to compare BH with other techniques&#44; some studies have shown greater survival of vascular access with the BH technique&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">21</span></a> However&#44; recent publications&#44; such as that of MacRae&#44; a randomised clinical trial that included 70 patients with BH&#44; or the aforementioned of Chan et al&#46; study&#44; have not shown such a potential benefit&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">22&#44;24</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">One of the aspects assessed in our study is the reduction in clotting time at the end of the HD session&#44; which was significant in our population &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In our study&#44; the fact that 75&#37; of patients received anticoagulation or antiplatelet therapy has made it possible to predetermine our results&#44; as they were patients with a higher risk of bleeding&#46; Grau et al&#46; observed a reduction in haemostasis time with the BH technique&#44; although the sample was very small&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">8</span></a> In turn&#44; in the aforementioned Vaux et al&#46; study&#44; bleeding time with the BH technique vs the conventional technique was also reduced&#58; median 7&#46;9 &#40;6&#46;3&#8211;10&#46;4&#41; vs&#46; 9&#46;1<span class="elsevierStyleHsp" style=""></span>min &#40;6&#46;9&#8211;11&#46;3&#41; respectively&#44; but without reaching statistical significance&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">21</span></a> However&#44; other studies have not proven a reduction in clotting times and some studies have even observed an increased bleeding time&#44; which determined the abandonment of the BH technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">7&#44;24&#44;25</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">At the same time&#44; the inclusion of the BH technique has led to 5 patients to perform self-cannulation&#46; Although the results are contradictory&#44; especially in terms of home HD&#44; self-cannulation offers benefits to the patient&#58; increasing their autonomy less anxiety when the professional performing the puncture regularly is changed&#44; as well as reducing the number of puncture attempts&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">5&#44;18&#44;24</span></a> The BH technique could be a way of facilitating the option of self-cannulation&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In terms of pain management&#44; in our experience&#44; changing to the BH technique has benefitted our patients&#46; This is a biased population&#44; which may determine our results&#46; Some observational studies&#44; such as that by Ward et al&#46;&#44; have also observed a reduction of up to 81&#37; in pain perception with this technique as compared to conventional techniques&#59; however others&#44; such as the van Loon et al&#46; study&#44; did not observe any differences in pain probably due to the routine use of local anaesthetics in classic punctures &#40;30&#37; use in rope-ladder punctures vs 8&#37; in BH punctures&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">6&#44;26</span></a> In randomised clinical trials differences in pain have not been demonstrated&#44; and some studies have shown even an adverse effect of the BH technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">10&#44;21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; the presence of BH-associated complications&#44; such as the need to change BH tunnels due to problems during cannulation&#44; is not widely described&#46; In our study&#44; it was necessary to change the technique in 2 cases after admission to other centres where the BH was not used&#46; Once the patients returned to our unit&#44; it was necessary to restart the process&#46; In the other 7 cases&#44; the need to change the tunnel&#44; was likely due to a change in professionals and this is despite the organisational efforts of the unit and the nursing staff&#39;s commitment&#46; This is an essential aspect for the development of these techniques at our institutions&#44; where in addition to the constant turnover of professionals there is an absence of specific training in the field of HD&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Our study has the usual limitations of an observational study without a control group and with a relatively short follow-up period&#46; The patient selection present significant bias&#46; However&#44; broadening the range of puncture alternatives and improving knowledge of other techniques are relevant aspects of our results&#46; Furthermore&#44; although the follow-up period is not very long and the number of patients is reduced&#44; our experience is the broadest in our community to date&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">The BH technique may be a valid puncture alternative for patients on HD&#44; especially in some situations in which the alternative is area puncture&#46; It may offer some benefits such as facilitating self-cannulation or reducing waiting times at the end of HD sessions&#46; However&#44; to improve this technique&#44; it is necessary both to increase dissemination and to reduce the negative aspects that have been detected&#44; and to have motivated professional nursing staff&#46; It is likely that the frequent turnover of staff&#44; absence of HD specialisation and lack of training in the technique may be resolved with a greater institutional commitment to healthcare professionals and&#44; therefore&#44; to patients&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">Ms Laura Baena has been a lecturer on different courses sponsored by Nipro Corp&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Dr Jos&#233; L&#46; Merino has been a lecturer on different courses sponsored by Nipro Corp&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The other authors declare they have no conflicts of interest&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Nipro Corp&#46; has not taken part in the design&#44; analysis or drafting of this study&#46;</p></span></span>"
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            1 => "Haemodialysis"
            2 => "Haemostasis"
            3 => "Self-puncture"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec838002"
          "palabras" => array:4 [
            0 => "<span class="elsevierStyleItalic">Buttonhole</span>"
            1 => "Hemodi&#225;lisis"
            2 => "Hemostasia"
            3 => "Autopunci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The buttonhole &#40;BH&#41; puncture technique for arteriovenous fistulas is an alternative to the classical staggered puncture&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Purpose</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present 3 years&#8217; results incorporating the BH puncture technique for arteriovenous fistulas in our dialysis unit&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty-two patients were started on BH technique&#44; 15 men and 7 women &#40;mean age&#58; 62 years&#59; SD&#58; 12&#41;&#44; with time spent on dialysis when starting the BH technique of 34 months &#40;SD&#58; 34&#44; median&#58; 27&#44; range&#58; 3&#8211;136&#41;&#46; Seven patients received acenocoumarol and 9 antiplatelet agents&#46; The vascular access median time at the beginning of the technique was 27 months &#40;range&#58; 3&#8211;252&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Between 5 and 8 consecutive dialysis sessions were necessary to achieve a proper tunnel puncture&#46; No patient suffered major complications&#46; The average time on BH technique until December 2015 was 12 months &#40;SD&#58; 10&#44; median&#58; 9&#44; range&#58; 1&#8211;45&#41;&#46; By the end of the study&#44; 5 patients were performing self-puncture&#46; Haemostasis times post-dialysis were reduced from 18&#46;6<span class="elsevierStyleHsp" style=""></span>min &#40;SD&#58; 8&#44; prior to the BH technique&#41;&#44; to 12&#46;2<span class="elsevierStyleHsp" style=""></span>min &#40;SD&#58; 3 after BH&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0005&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The BH technique is an alternative puncture technique for dialysis patients&#46; Self-puncture and reduction in haemostasis time are potential beneficial aspects&#46; A greater diffusion of this technique in the haemodialysis units would allow it to be better applied&#46; A highly motivated nursing staff is key and a necessary condition for its implementation&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Purpose"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material and methods"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
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      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La t&#233;cnica de punci&#243;n de <span class="elsevierStyleItalic">buttonhole</span> &#40;BH&#41; o de ojal para f&#237;stulas arteriovenosas es una alternativa a la punci&#243;n escalonada cl&#225;sica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mostramos la experiencia en nuestra unidad de hemodi&#225;lisis tras la incorporaci&#243;n de esta t&#233;cnica a la pr&#225;ctica cl&#237;nica diaria&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se ha aplicado la t&#233;cnica de BH a 22 pacientes&#44; 15 hombres y 7 mujeres&#44; con una edad media de 62 a&#241;os &#40;DE&#58; 12&#41;&#44; con un tiempo en di&#225;lisis en el momento de iniciar la t&#233;cnica de BH de 34 meses &#40;DE&#58; 34&#59; mediana&#58; 27&#59; rango&#58; 3-136&#41;&#46; Siete pacientes recib&#237;an acenocumarol y 9 estaban antiagregados&#46; La mediana de tiempo con el acceso vascular al inicio de la t&#233;cnica de BH fue de 27 meses &#40;rango&#58; 3-252&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fueron necesarias entre 5 y 8 sesiones consecutivas de di&#225;lisis para la consecuci&#243;n de un correcto t&#250;nel de canalizaci&#243;n&#46; Ning&#250;n paciente present&#243; complicaciones mayores&#46; El tiempo medio en la t&#233;cnica de BH fue de 12 meses &#40;DE&#58; 10&#59; mediana&#58; 9&#59; rango&#58; 1-45&#41;&#46; Al final del periodo de estudio 5 pacientes realizaban autopunci&#243;n&#46; El tiempo de hemostasia posdi&#225;lisis se redujo de 18&#44;6<span class="elsevierStyleHsp" style=""></span>min &#40;DE&#58; 8&#41; previamente a la t&#233;cnica de BH a 12&#44;2 &#40;DE&#58; 3&#41; posteriormente a su utilizaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0005&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La t&#233;cnica de BH es una alternativa de punci&#243;n en hemodi&#225;lisis&#46; Puede presentar aspectos beneficiosos como la autopunci&#243;n o la reducci&#243;n de los tiempos de hemostasia&#46; Una mayor difusi&#243;n en las unidades de hemodi&#225;lisis ser&#237;a necesaria para mejorar en su aplicaci&#243;n adecuada&#46; El personal de enfermer&#237;a altamente motivado es clave y condici&#243;n necesaria para su implantaci&#243;n&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Material y m&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
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      ]
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    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Baena L&#44; Merino JL&#44; Bueno B&#44; Mart&#237;n B&#44; S&#225;nchez V&#44; Caserta L&#44; et al&#46; Instauraci&#243;n de la t&#233;cnica de <span class="elsevierStyleItalic">buttonhole</span> como alternativa de punci&#243;n para las f&#237;stulas arteriovenosas&#46; Experiencia de un centro en 3 a&#241;os&#46; Nefrologia&#46; 2017&#59;37&#58;199&#8211;205&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Some of the information shown here has been presented as a poster at the 2nd Parc Taul&#237; International Vascular Access Symposium&#44; held in Sabadell on the 7th and 8th April 2016&#46;</p>"
      ]
    ]
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        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BioHole&#46; Device for the creation of tunnel tracks for buttonhole cannulation&#46;</p>"
        ]
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        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Haemostasis times prior to and following the buttonhole technique&#46; The median time &#40;interquartile range&#41; until onset of haemostasis using the technique prior to BH &#40;pre-BH&#41; was 15 &#40;15&#8211;20&#41; min&#44; and after a month of the BH technique &#40;post-BH&#41; the median was 10 &#40;10&#8211;15&#41; min &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean age &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male&#47;female</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Aetiology of kidney disease</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Malignant HTN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Glomerulopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Polycystic kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bilateral nephrectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">HTN</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Heart disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Oral anticoagulation therapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Antiplatelet agents</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of haemodialysis</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High-flux HD &#40;6 sessions&#47;week&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High-flux HD &#40;5 sessions&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High-flux HD &#40;4 sessions&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High-flux HD &#40;3 sessions&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High-flux HD &#40;2 sessions&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous vascular access</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous tunnelled catheter</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Analytics</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean haemoglobin &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean haematocrit &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Baseline data&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">BH&#58; <span class="elsevierStyleItalic">buttonhole</span>&#59; AVF&#58; arteriovenous fistula&#59; LHB&#58; left humero-basilic&#59; RHC&#58; right humero-cephalic&#59; LHC&#58; left humero-cephalic&#59; mixed&#58; combination of rope-ladder and area&#59; RRC&#58; right radiocephalic&#59; LRC&#58; left radiocephalic&#59; RRT&#58; Renal replacement therapy&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of AVF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of puncture prior to BH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Months of AVF at the start of BH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Months on RRT at the start of BH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Time with BH &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Status of the BH in Dec 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">252&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death &#40;cerebral haemorrhage&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not functioning &#40;thrombosis of the AVF&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Abandonment of BH &#40;suspected infection&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHB&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Abandonment of BH &#40;failure of BH&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rope-ladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Characteristics of vascular access and status at the end of the study&#46;</p>"
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