What is the treatment for a bleeding arteriovenous (AV) fistula?

From the Guidelines

The treatment for a bleeding arteriovenous (AV) fistula involves immediate direct pressure at the bleeding site, and if bleeding persists, endovascular therapeutic options such as thrombolysis and/or thrombectomy, balloon angioplasty, or stent graft placement may be necessary to restore patency and prevent further complications 1.

Initial Management

The initial step in managing a bleeding AV fistula is to apply direct pressure at the bleeding site for at least 10-15 minutes without peeking, using sterile gauze or a clean cloth, and elevating the affected limb above heart level if possible. If bleeding persists after 15 minutes of continuous pressure, it is crucial to continue compression and seek emergency medical attention immediately.

Endovascular Intervention

For cases where bleeding is associated with thrombosis or stenosis of the AV fistula, endovascular therapeutic options have largely superseded open surgical techniques for restoration, as suggested by the SIR Standards and Practice Committee guidelines 1. These options include mechanical thrombectomy, pharmacologic thrombolysis, balloon angioplasty, stent graft or stent placement, or a combination of these techniques. The clinical success rate for thrombolysis and/or thrombectomy is reported to be between 75% to 94% 1.

Prevention and Monitoring

Prevention strategies are crucial and include proper cannulation technique, adequate hemostasis post-dialysis, and regular assessment of the fistula's integrity. Patients should be educated to avoid blood pressure measurements, venipuncture, or tight clothing on the fistula arm. After a bleeding episode, the fistula should be monitored for signs of infection or thrombosis.

Key Considerations

• Early diagnosis and intervention within 24 to 48 hours are critical for restoring patency and preventing further complications 1.
• The choice of endovascular therapy should be tailored to the individual patient's condition, considering factors such as the location and extent of thrombosis or stenosis.
• Coordination of care with a multidisciplinary team, including nephrologists, radiologists, and vascular surgeons, is essential for optimal management of AV fistula complications.

From the Research

Treatment Options for Bleeding Arteriovenous (AV) Fistula

• The management of AV fistula hemorrhage has historically included:
  • Direct pressure 2
  • Tourniquet use 2
  • Surgical management 2, 3
• Endovascular intervention may be an alternative treatment modality in patients where surgery is not indicated 3
• Embolization techniques, such as:
  • Coil embolization with an anchor coil 4
  • Balloon-assisted direct percutaneous embolization with N-butyl cyanoacrylate and 50% glucose solution 3
  • Glue embolization with guide catheter dextrose push 5
• Treatment of complications, such as venous congestion, may include:
  • Anti-thrombin therapy 6
  • Dual antiplatelet therapy 6

Specific Embolization Techniques

• Anchor coil technique: involves inserting a coil into the varix to facilitate dense packing at the shunting site 4
• Balloon-assisted direct percutaneous embolization: involves using a balloon to assist in the embolization of the draining vein 3
• Glue embolization with guide catheter dextrose push: involves injecting a dilute concentration of glue slowly and continuously, with concomitant injection of dextrose 5% in water through the guide catheter 5