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Intra-Arterial Treatment for Subcutaneous or Intramuscular Bleeding in Extremities with Arteriovenous Fistula

Hemodialysis (HD) patients tend to be at a higher bleeding risk than healthy individuals, and massive bleeding can be life threatening (1). It is difficult to salvage arteriovenous fistula (AVF) in the bleeding extremities because hemostasis is given priority over retaining AVF function. This is the first report of HD patients in whom AVFs at the extremities with massive bleeding were salvaged through transarterial embolization (TAE). A 71-year-old woman on HD for 35 years was prescribed aspirin. A right distal forearm radial-cephalic AVF was used for HD. Right forearm bleeding rapidly occurred following minor blunt trauma. Contrast-enhanced computed tomography (CT) scan revealed subcutaneous bleeding in the right forearm (Fig. 1A, B). We performed angiography which revealed active extravasation of the contrast medium from the right anterior interosseous artery (Fig. 1C). After TAE was performed with gelatin sponge, arteriography demonstrated complete occlusion of the target vessels, and retention of the functional AVF (Fig. 1D). The use of the AVF for HD was resumed 27 days after the TAE. The patient was discharged from the hospital 60 days later. An 84-year-old woman on HD for 11 years developed chronic hepatitis C, and had a platelet count of 3.2 × 103/ mL. A left distal forearm ulnar-basilic AVF was used for HD. Left upper arm bleeding rapidly occurred after minor blunt trauma. Contrast-enhanced CT scan revealed intramuscular bleeding in the left upper arm (Fig. 2A, B). We performed angiography which revealed active extravasation of the contrast medium from small branches of the brachial artery (BA) (Fig. 2C). We performed TAE of the direct branches of the BA by using gelatin sponge and prevented occlusion of the forearm artery using balloon dilation on the peripheral side of the BA bleeding site. We subsequently collected the residual gelatin sponge in the BA prior to deflating the balloon. After TAE, arteriography demonstrated complete occlusion of the target vessels, and retention of the functional AVF (Fig. 2D). The use of the AVF for HD was resumed 3 days after the TAE. The patient was discharged from the hospital 25 days later. Patients with end-stage renal disease are well known to have an increased incidence of bleeding complications (2). When extremity bleeding is refractory to direct pressure, stronger external pressure may obstruct the AVF and make it nonfunctional. Moreover, it is often difficult to stop the bleeding or identify all of its sources using surgical intervention. Angiography is especially advantageous in hemodynamically unstable patients since the point of Fig. 1 In a 71-year-old woman, bleeding occurred in the right forearm containing an arteriovenous fistula. (A, B) Contrast-enhanced computed tomography scans in horizontal (A) and coronal (B) views revealing a hematoma and extravasation of the contrast medium in the right forearm (white arrows). (C) Angiography revealed active extravasation of the contrast medium from the right anterior interosseous artery (RAIA) (black arrows). (D) After embolization, arteriography demonstrated no further extravasation of the contrast medium. CV, cephalic vein; RA, radial artery.