Tuesday Advanced Cases

Critical Cases – Fistula Hemorrhage Emergency!

Kane McKenzie M.D.

Dialysis Fistula Bleeding Aneurysm

HPI

69 year-old female with a past medical history of ESRD on HD, HIV, Pulmonary HTN, HFrEF (EF 25%), anemia, thrombocytopenia presents after dialysis with left upper extremity pain and swelling. The dialysis RN reports there was shiny skin present over the LUE AVF and they cannulated to avoid that area, the patient received one hour of treatment that was stopped due to pain. Patient reports the her arm above the AVF has been slowly enlarging

Vitals

BP: 98/54, HR: 78, RR 20, T: 97.6

Exam:

Alert and oriented, no acute distress, chronically-ill appearing

LUE with no external bleeding, fistula has a palpable thrill. Swelling and tenderness are present above the AVF, over the medial upper arm.

Cap refill >2 seconds

Rest of exam unremarkable

Clinical Course

-CTA upper extremity was obtained to assess for active bleeding – showed AV fistula with aneurysmal dilatation, large hematoma with upper arm approximating a volume of 1000cc. No evidence of active hemorrhage

-Direct pressure was held above and below the AVF.

-Repeat BP 58/24

-Central line placed, resuscitated with 2U PRBC, 1 platelets, 1 FFP. Required norepinephrine and vasopressin drip

-Taken level 0 to OR for Brachiocephalic fistula ligation and hematoma evacuation with 500cc hematoma removed

-The patient was stabilized and recovered after being treated for hemorrhagic shock

Pearls

-AVF aneurysms can develop from repeated ruptures, increased venous pressure, and immunosuppression. They are usually asymptomatic, rarely rupture. Aneurysm formation is present in 5-7% of AVF

-Skin changes, pain, high output heart failure, and thrombosis can result from aneurysms and are an indication for operative management.

-AVF pseudoaneurysms can develop from extravasation of blood from cannulation sites, are more prone to rupture, develop more quickly

-Aneurysms/pseudoaneurysms can be identified by their shiny, thin, atrophic skin. In more severe cases can present with necrosis.

-Apply pressure and/or tourniquet above and below the AVF if life threatening hemorrhage is suspected

-Emergent consultation with vascular surgery warranted for operative repair

References:

Pasklinsky G, Meisner RJ, Labropoulos N, Leon L, Gasparis AP, Landau D, Tassiopoulos AK, Pappas PJ. Management of true aneurysms of hemodialysis access fistulas. J Vasc Surg. 2011 May;53(5):1291-7. doi: 10.1016/j.jvs.2010.11.100. Epub 2011 Jan 26. PMID: 21276676.

Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP; National Kidney Foundation. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020 Apr;75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001. Epub 2020 Mar 12. Erratum in: Am J Kidney Dis. 2021 Apr;77(4):551. PMID: 32778223.

Saeed F, Kousar N, Sinnakirouchenan R, Ramalingam VS, Johnson PB, Holley JL. Blood Loss through AV Fistula: A Case Report and Literature Review. Int J Nephrol. 2011;2011:350870. doi: 10.4061/2011/350870. Epub 2011 May 30. PMID: 21716705; PMCID: PMC3118665.

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