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

Management of Bleeding Arteriovenous (AV) Fistula

Apply direct manual pressure immediately to the bleeding site and maintain it for at least 10-15 minutes without interruption—this is the first-line intervention for any AV fistula hemorrhage. 1, 2

Immediate Hemorrhage Control

Direct manual pressure remains the primary emergency intervention, with the following critical considerations:

• Never apply a tourniquet except as an absolute last resort in life-threatening exsanguination, as this can compromise the entire access and lead to thrombosis 2
• Maintain continuous pressure without "peeking" to check if bleeding has stopped—premature release restarts the hemorrhage 1
• If manual pressure fails after 15 minutes, consider placement of a clamp device or suture placement at the bleeding site 2
• Topical hemostatic agents (such as thrombin-based products) can be applied as adjunctive therapy while maintaining pressure 2

Emergency Department Triage and Risk Stratification

The severity of AV fistula bleeding varies significantly, with approximately 6% presenting as life-threatening and 32% as high-risk emergencies 2:

• Life-threatening presentations 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, 2
• Approximately 78% of bleeds occur post-cannulation, while 18% represent spontaneous bleeding from access complications such as pseudoaneurysms or skin breakdown 2

Resuscitation Priorities

For hemodynamically unstable patients:

• Establish IV access in the contralateral extremity and initiate crystalloid resuscitation 3
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL, avoiding over-resuscitation which can increase bleeding risk 3
• Correct coagulopathy with appropriate blood products (target platelet count >50,000, fibrinogen >120 mg/dL) 3
• Review and temporarily hold antiplatelet agents and anticoagulants in consultation with nephrology 3

Vascular Surgery Consultation

Immediate vascular surgery consultation is mandatory in the following scenarios 2:

• Bleeding that fails to respond to 15-20 minutes of direct pressure
• Bleeding from a visible pseudoaneurysm or aneurysmal segment
• Evidence of skin compromise or threatened skin viability over the access 3, 1
• Spontaneous bleeding without recent cannulation (suggests underlying structural problem) 1, 2
• Any bleeding associated with signs of infection (erythema, warmth, purulent drainage) 3, 4

Having a vascular surgeon evaluate patients in the emergency department reduces related readmissions by 88% (25% vs 2.9%) and decreases need for subsequent interventions 2. This represents the strongest evidence for improved outcomes.

Definitive Management Based on Underlying Cause

Post-Cannulation Bleeding

• Usually responds to prolonged direct pressure (10-20 minutes) 2
• If recurrent, consider suture placement at the cannulation site 2
• Evaluate for adequate needle size and proper cannulation technique to prevent future episodes 3

Pseudoaneurysm-Related Bleeding

Pseudoaneurysms require surgical intervention when they 3, 1:

• Exceed twice the diameter of the graft
• Demonstrate rapid expansion
• Threaten viability of overlying skin
• Are associated with infection
• Cause spontaneous bleeding

Never cannulate through or near a pseudoaneurysm—this directly precipitates catastrophic rupture 1, 4. Surgical treatment involves resection and interposition graft placement 3.

Infection-Related Bleeding

• Initiate broad-spectrum antibiotics immediately if infection is suspected 4
• Uncontrolled infection at the AV anastomosis may require immediate surgical exploration with resection of infected tissue and possible complete access dismantling 5
• Systemic sepsis from access infection requires surgical removal of infected segments 5

Disposition and Follow-Up

Approximately 41% of patients with AV fistula bleeding require hospital admission for definitive management 2:

• Discharge criteria: Bleeding completely controlled, hemodynamically stable, no high-risk features, reliable patient with close follow-up arranged 2
• Admission criteria: Hemodynamic instability, failure of hemorrhage control, need for surgical intervention, or concerning underlying pathology 2
• Tunneled dialysis catheter placement is required in approximately 15% of hospitalized patients when the access cannot be salvaged 2

Critical Post-Event Management

After hemorrhage control:

• Avoid cannulation of the affected site until proper evaluation by vascular surgery has been completed 4, 2
• Arrange urgent vascular surgery follow-up within 48-72 hours for all bleeding episodes 2
• Consider fistulography or duplex ultrasound to identify underlying stenosis or other structural abnormalities 3, 4
• At 90 days, 59% of patients represent to the emergency department, with 23% for access-related causes, highlighting the importance of close surveillance 2

Common Pitfalls to Avoid

• Delaying vascular surgery consultation leads to worse outcomes, including higher readmission rates and need for new access creation 2
• Premature release of pressure to "check" if bleeding has stopped restarts hemorrhage 1
• Attempting cannulation through compromised skin or near aneurysms precipitates catastrophic bleeding 1, 4
• Failure to identify and address underlying stenosis results in recurrent thrombosis and bleeding complications 3
• Inadequate follow-up: Only 45.5% of patients achieve 6-month follow-up with an access surgeon, representing a major gap in care 2

Long-Term Access Outcomes

• 45.5% of patients require an intervention on their access following a bleeding episode (45.5% open surgical, 54.6% endovascular) 2
• Among open operations, 60% are access revisions and 40% are ligations 2
• 22.7% of patients require new AV access creation within 1 year of a bleeding episode 2
• The majority (83.3%) of patients undergoing fistulography require subsequent intervention, emphasizing the importance of identifying underlying pathology 2