Dialysis Access Hemorrhage: Access Rescue from a Surgical Emergency.

BACKGROUND: Hemorrhage from a dialysis access can be a life-threatening condition. This study details our experience using access rescue strategies, including in situ graft replacement, primary repair, or conversion to an autogenous fistula, coupled with treatment of central vein occlusion to maintain access usage in patients presenting with conduit hemorrhage.

METHODS: During a 3-year period (2012-2014), 26 patients (14 women, 12 men) on chronic hemodialysis were treated for access conduit bleeding (n = 18) or life-threatening hemorrhage (n = 8), located in the upper extremity (n = 23) or thigh (n = 3). All patients had developed bleeding from a skin eschar/ulcer over a bovine (n = 9) or polytetrafluoroethylene (n = 9) bridge graft, or aneurysmal autogenous fistula (n = 8). A retrospective review of outcome relative to clinical signs, etiology of conduit bleeding (infection, wall erosion), and the type of rescue procedure(s) was performed. Duplex ultrasound testing was used to guide therapy based on the presence of aneurysmal degeneration, perigraft fluid, or access flow pattern indicative of venous outflow obstruction.

RESULTS: One-half of the patients were taken emergently to the operating room for hemorrhage control or impending rupture of an infected false aneurysm, the remaining repaired on an urgent basis. In 18 patients, emergency room personnel attempted control of access site bleeding by suturing (n = 14) or tourniquet (n = 4). Dialysis access salvage was achieved in 22 (85%) of 26 patients by in situ conduit replacement using a rifampin-soaked polytetrafluoroethylene conduit (n = 19) or primary repair (n = 3). Two patients with sepsis and ruptured, infected false aneurysm were treated by ligation, and 2 patients with nonsalvable access had conversion to an autogenous fistula. One-third of rescued accesses (n = 7) had staged endovascular treatment of central vein stenosis. One patient died within 30 days. All dialysis access revisions remained patent and used for immediate dialysis (n = 5), within 4-5 weeks (n = 19), or after vein maturation (n = 2). One replaced graft was revised for infection. Positive blood or bleeding site cultures were obtained from 9 (45%) of 20 patients tested.

CONCLUSIONS: Salvage of a functional dialysis access is possible in the majority of patients presenting with conduit hemorrhage. Loss of wall integrity, infection, and venous hypertension were etiologic factors. Application of in situ graft replacement strategies known to be effective in the treatment of graft infection should be considered in the management of this surgical emergency.