What is the best approach to manage bleeding in a patient with an arteriovenous (AV) fistula?

Management of Arteriovenous Fistula Bleeding

Apply immediate, continuous direct manual pressure to the bleeding site for at least 10-15 minutes without interruption—this is the first-line, life-saving intervention for any AV fistula hemorrhage. 1

Immediate Hemorrhage Control

• Maintain uninterrupted direct pressure for the full 10-15 minutes without "peeking" to check if bleeding has stopped, as premature release will restart the hemorrhage and reset the clotting process. 1

• If the patient or bystander is applying pressure, ensure they understand not to lift their hand to check—this is a critical pitfall that leads to continued bleeding. 1

• Apply pressure directly over the bleeding site, not proximal or distal to it, using firm sustained compression. 1

Emergency Assessment and Resuscitation

Life-threatening presentations requiring immediate intervention include active pulsatile bleeding, hemodynamic instability, or signs of significant blood loss. 1

• Establish IV access in the contralateral extremity (never the arm with the fistula) and initiate crystalloid resuscitation if the patient is hemodynamically unstable. 1

• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL, but avoid over-resuscitation which paradoxically increases bleeding risk by disrupting clot formation. 1

• Correct coagulopathy with appropriate blood products targeting platelet count >50,000/μL and fibrinogen >120 mg/dL. 1

• High-risk features demanding urgent intervention include bleeding from aneurysmal segments, compromised overlying skin, or failure of initial pressure control after 15-20 minutes. 1

When to Obtain Immediate Vascular Surgery Consultation

Vascular surgery consultation is mandatory and should be obtained immediately in the following scenarios: 1

• Bleeding that fails to respond to 15-20 minutes of direct pressure 1
• Bleeding from a visible pseudoaneurysm or aneurysmal segment 1
• Compromised or necrotic overlying skin 1
• Signs of infection at the bleeding site 1
• Hemodynamic instability despite resuscitation 1

Recent data from 2025 demonstrates that having an access surgeon evaluate patients in the emergency department results in significantly fewer related readmissions (2.9% vs 25%, P=0.02) and fewer 1-year interventions (17.7% vs 43.8%, P=0.02). 2 This underscores the importance of early specialist involvement.

Management Based on Underlying Cause

Pseudoaneurysm-Related Bleeding

Pseudoaneurysms require surgical intervention when they exceed twice the diameter of the native vessel, demonstrate rapid expansion, threaten viability of overlying skin, are associated with infection, or cause spontaneous bleeding. 1

• Never cannulate through or near a pseudoaneurysm, as this directly precipitates catastrophic rupture—this is a critical error that must be avoided. 1

• 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. 3

• 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. 3

Post-Cannulation Bleeding

The majority (78.8%) of AV fistula bleeds are post-cannulation hemorrhages. 2 Emergency department interventions include: 2

• Manual pressure (most common, 37.9% of cases) 2
• Suture placement (25.8% of cases) 2
• Topical hemostatic agents (15.2% of cases) 2
• Clamp devices (13.6% of cases) 2

A novel prehospital technique using a simple bottle cap to apply focal pressure has been successfully described, though this requires proper positioning and monitoring. 4

Critical Post-Event Management

Avoid cannulation of the affected site until proper evaluation by vascular surgery has been completed—this is essential to prevent recurrent bleeding and identify underlying structural problems. 1

• Arrange urgent vascular surgery follow-up within 48-72 hours for all bleeding episodes, as this is a sentinel event indicating access dysfunction. 1

• 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. 3

• Be aware that 59% of patients will represent to the emergency department within 90 days, with 23% of readmissions being for related causes. 2

• At 1 year, 22.7% of patients will require new AV access creation, highlighting the serious long-term implications of bleeding events. 2

Bridging Dialysis Access

If the fistula is compromised and cannot be used for dialysis, placement of a temporary tunneled dialysis catheter may be necessary as bridging therapy. 3

• 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. 3

• Tunneled dialysis catheters were required in 15.2% of hospitalized patients with AV fistula bleeding in recent data. 2

Common Pitfalls to Avoid

• Premature release of pressure to check if bleeding has stopped—this is the most common error 1
• Cannulating through or near pseudoaneurysms—this causes catastrophic rupture 1
• Delaying vascular surgery consultation when bleeding fails initial pressure control 1
• Over-resuscitation with fluids—this disrupts clot formation and worsens bleeding 1
• Poor follow-up—only 45.5% of patients achieve 6-month follow-up with an access surgeon, contributing to poor outcomes 2