A bleeding dialysis fistula can cause a fatal hemorrhage, so we want to act promptly and have all supplies ready. When direct pressure and topical hemostatics have failed, proceed with a suture to control the bleed.
You need two tourniquets: one above, and one below the AV fistula, since blood supply is coming from both directions.
We are using a standard tourniquet proximally. Avoid compression of the fistula itself.
Distally we inflate a blood pressure cuff that we connect to a portable sphygmomanometer, and lock to maintain pressure.
Prep the skin with antiseptic solution. Inject local anesthetic with epinephrine, which may also help slow the bleeding. Drape the patient.
The type of suture to use is a nonabsorbable monofilament. We used 4-0 polypropylene suture. More importantly, use a taper-point needle. We don’t want a cutting needle because that may cause more damage to the fistula.
A figure of eight suture is a good option for hemorrhage control anywhere, including here. Other described techniques are a horizontal mattress suture or a purse string suture. However, in a critical situation it’s best to stick with a technique you know well.
Slowly release the tourniquet to see if you have adequate hemorrhage control.
Observe this patient for a couple of hours to make sure there is no rebleeding. Consult vascular surgery because the shunt likely needs a venogram to evaluate for patency before use.