Management of Bleeding Arteriovenous (AV) Fistula

Immediate Hemorrhage Control

The American College of Surgeons recommends applying direct manual pressure immediately to the bleeding site and maintaining it for at least 10-15 minutes without interruption, as this is the first-line intervention for any AV fistula hemorrhage 1
Maintaining continuous pressure without "peeking" to check if bleeding has stopped is crucial, as premature release restarts the hemorrhage 1

Life-threatening presentations of AV fistula bleeding include active pulsatile bleeding, hemodynamic instability, or signs of significant blood loss requiring immediate resuscitation 2
High-risk features include bleeding from aneurysmal segments, compromised overlying skin, or failure of initial pressure control 1

The American College of Emergency Physicians recommends establishing IV access in the contralateral extremity and initiating crystalloid resuscitation for hemodynamically unstable patients 2, 3
Transfusing packed red blood cells to maintain hemoglobin >7 g/dL, avoiding over-resuscitation which can increase bleeding risk, is recommended 2, 3
Correcting coagulopathy with appropriate blood products (target platelet count >50,000, fibrinogen >120 mg/dL) is essential 2, 3

Immediate vascular surgery consultation is mandatory in scenarios such as bleeding that fails to respond to 15-20 minutes of direct pressure 2
The American Society of Nephrology recommends considering vascular surgery consultation for bleeding from a visible pseudoaneurysm or aneurysmal segment 4

Pseudoaneurysms require surgical intervention when they exceed twice the diameter of the graft, demonstrate rapid expansion, threaten viability of overlying skin, are associated with infection, or cause spontaneous bleeding 4, 1
The Society of Interventional Radiology recommends avoiding cannulation through or near a pseudoaneurysm, as this directly precipitates catastrophic rupture 1, 5

The American College of Surgeons recommends avoiding cannulation of the affected site until proper evaluation by vascular surgery has been completed 5
Arranging urgent vascular surgery follow-up within 48-72 hours for all bleeding episodes is crucial 5
Considering fistulography or duplex ultrasound to identify underlying stenosis or other structural abnormalities is recommended 6, 7, 5

Endovascular stent graft placement for pseudoaneurysms has an overall patency rate of 81.5% but carries a complication rate of 28.9%, with a 5-fold increased relative risk compared to treatment of stenosis alone, according to the American College of Radiology 8
Surgical management typically involves placement of an interposition prosthetic graft, which may be tunneled in situ or extra-anatomically depending on the presence of infection, as recommended by the American College of Radiology 8

Consider fistulography or duplex ultrasound to identify underlying stenosis or other structural abnormalities, as stenosis is present in close to 100% of cases preceding thrombosis or bleeding complications, according to the American Journal of Kidney Diseases 9

If the fistula is compromised and cannot be used for dialysis, placement of a temporary tunneled dialysis catheter may be necessary as bridging therapy, as suggested by the American College of Radiology 8
If there is clinical concern for systemic infection or bacteremia, treat the underlying infection before placing a tunneled catheter—a temporary non-tunneled catheter can be used for immediate dialysis access during this period, according to the American College of Radiology 8