Non-surgical interventions to control bleeding from arteriovenous fistulas and grafts inside and outside the hemodialysis unit: a scoping review

Abstract

Background: Prolonged bleeding from arteriovenous fistulas (AVF) and arteriovenous grafts (AVG) associates with worse outcomes; Within the hemodialysis unit these outcomes include anemia and quality of life disruptions, and outside the hemodialysis unit includes fatal hemorrhage. However, various guidelines for AVF/AVG bleeding management inside and outside the hemodialysis unit lack consensus.

Methods: A scoping review was conducted of four databases, from inception to 17 February 2024. The study population was hemodialysis patients experiencing bleeding from AVF or AVG. Studies that assessed non-operative management were included.

Results: Sixteen studies met inclusion criteria. Most (14/16) addressed post-cannulation bleeding from AVF/AVG within the dialysis unit. Compared with standard dressings, hemostatic dressings (chitosan-, cellulose- or thrombin-based) decreased post-cannulation bleeding time at arterial and venous site 35.7%-84.0% (P < .05) and 38.5%-78.7% (P < .05), respectively. Use of chitosan-based dressings decreased percentage of patients bleeding 4-min post-cannulation by 16.3%-39.2%. One pilot observational study demonstrated no access thromboses or infections with short-term use of a compression device within the hemodialysis unit. However, the role of compression devices and tourniquets within the dialysis unit remains unclear, despite widespread use. Long-term AVF/AVG survival was not reported in any study. Limited research confirms that devices are effective in prevention of catastrophic out-of-hospital bleeding. It remains uncertain if device availability enhances patient confidence in managing out-of-hospital bleeding. This may impact patient choices around dialysis modality, access and transplant, but this remains uncertain.

Conclusions: In hemodialysis patents with bleeding from AVF/AVG, several alternative dressings or devices decrease post-cannulation bleeding time within the hemodialysis unit. Existing research has not established criteria on when it might be appropriate to use specialized dressings. There is very limited research on methods to control bleeding from AVF/AVG outside the hemodialysis unit. More data are required before evidence-based guidelines can be made. Recommendations for future research are provided.

Keywords: arteriovenous fistulas; arteriovenous grafts; hemodialysis; hemorrhage; post-cannulation bleeding.