SAGE-Hindawi Access to Research International Journal of Nephrology Volume 2011, Article ID 350870, 6 pages doi:10.4061/2011/350870 Review Article Blood Loss through AV Fistula: A Case Report and Literature Review Fahad Saeed, Nadia Kousar, Ramapriya Sinnakirouchenan, Vijaya S. Ramalingam, Philip B. Johnson, and Jean L. Holley College of Medicine at Urbana-Champaign, University of Illinois, 611 W Park Street, Urbana, IL 61801, USA Correspondence should be addressed to Fahad Saeed, fahadsaeed20@gmail.com Received 3 January 2011; Revised 10 March 2011; Accepted 24 March 2011 Academic Editor: Greg Tesch Copyright © 2011 Fahad Saeed et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Little has been written about acute blood loss from hemodialysis vascular access. We describe a 57-year-old Caucasian male with an approximately 7 gm/dL drop in hemoglobin due to bleeding from a ruptured aneurysm in his right brachiocephalic arteriovenous ﬁstula (AVF). There was no evidence of ﬁstula infection. The patient was successfully managed by blood transfusions and insertion of a tunneled dialysis catheter for dialysis access. Later, the ﬁstula was ligated and a new ﬁstula was constructed in the opposite arm. Aneurysm should be considered in cases of acute vascular access bleeding in chronic dialysis patients. 1. Introduction Acute blood loss through vascular access can be a life threatening problem. The case under discussion highlights the importance of vascular access monitoring and surveil- lance to prevent failure. Blood loss through AVF can be from aneurysms, stenosis and subsequent rupture, infection, trauma, suicide and, use of anticoagulants and antiplatelet drugs. Common causes of blood loss through the AV ﬁstula in ESRD patients are also reviewed in the discussion part. 2. Case A 57-year-old Caucasian man with a past medical history of benign essential hypertension, dyslipidemia, coronary artery disease status post1 coronary artery bypass grafting, systolic congestive heart failure secondary to ischemic cardiomyopa- thy, type 1 diabetes mellitus with associated complications of diabetic retinopathy, neuropathy and nephropathy, h/o ischemic stroke, Human Immunodeﬁciency Virus (HIV) posi- tivity since 1992, and end-stage renal disease on hemodialysis through a right arm brachiocephalic AV ﬁstula (AVF) created approximately ﬁve years ago presented to the emergency room (ER) with bleeding from his AVF. He started having problems with this AV ﬁstula almost a year previously when he underwent an AV ﬁstulogram due to decreased dialysis clearance. The ﬁstulogram identiﬁed two areas of venous stenosis and an aneurysmal dilatation in the proximal portion of the outﬂow vein. No central vein stenosis was seen. Successful angioplasty of the two sequential stenoses was performed with establishment of good ﬁstula ﬂow. Five months after this procedure, prolonged ﬁstula bleeding after a routine dialysis led to another AV ﬁstulogram which demonstrated a recurrent stenosis of the outﬂow tract in the cephalic vein. Angioplasty was again successfully performed with no visible residual stenosis on postoperative ﬁstulo- gram. No routine access ﬂow monitoring was performed in the dialysis unit. No signiﬁcant dialysis access issues were observed until two weeks before the current presen- tation when dialysis nurses observed aneurysmal dilatation of his AV ﬁstula and recurrent prolonged bleeding from the cannulation site. Vascular surgery appointment was scheduled and pending. His home medications included aspirin 81 mg, clopidogrel 75 mg, lamivudine, atazanavir, lanthanum carbonate, carvedilol, amlodipine, valsartan, levothyroxine, insulin aspart, and lantus. Of note, he was on clopidogrel because of ischemic stroke while being on aspirin. He was on a combination of both antiplatelets for the last 4 years. On the day of presentation, an uncomplicated hemodialysis treatment concluded at 11 AM and the patient