4 and once a tract is formed, blunt needles are used. The area puncture technique involves needle insertion within a limited area of the ﬁstula. This technique is associated with more complications such as aneurysm formation, thinning of the skin at puncture sites, increased risk of bleeding along the needles, and longer bleeding time after needle withdrawal [31]. A standard part of patient teaching should be on man- aging interdialytic bleeding that includes compression with a clean cloth and calling the dialysis facility for instructions. They should also be instructed to go to the Emergency Room or call 911 for a more severe, uncontrollable bleed. All patients should be taught to compress a bleeding access, wash skin over access with soap and water daily and before dialysis, and also recognize signs and symptoms of infection. All patients should know to avoid carrying heavy items draped over the access arm, avoid wearing occlusive clothing, wear protective clothing over the exposed ﬁstula vein if working around machinery or sharp tools [11]. 3.5. Use of Antiplatelets, Anticoagulants, and Bleeding Ten- dencies. Platelet biochemical abnormalities in ADP and serotonin compounds along with thromboxane A2 leading to defective platelet aggregation may contribute to increased bleeding tendencies in dialysis patients [32, 33]. Platelet numbers are usually not low enough to cause increased bleeding [34]. Factor 8 and Von Willebrand factor alteration may also play a crucial role as can anemia by leading to defective platelet aggregation as demonstrated by in vitro studies [35, 36]. Hemodialysis improves these hemostatic complications but use of heparin during dialysis may be a contributory factor to increased bleeding tendencies from dialysis access sites including petechial hemorrhages, blood blisters, ecchymosis, and hematoma. It is unusual for acute access blood loss to occur due to an underlying coagulopathy though theoretically it may prolong bleeding from any other reason. Antiplatelet agents, such as dipyridamole and low- dose aspirin with or without sulﬁnpyrazone, aspirin plus clopidogrel, have been studied in an eﬀort to decrease graft thrombosis but conﬂicting evidence exists in this regard and no real recommendations exist for the use of antiplatelet agents to prevent graft thrombosis [37, 38]. In one clinical trial, role of aspirin plus clopidogrel versus double placebos was studied in preventing graft thrombosis [39], but the study was stopped because of a markedly increased risk of bleeding among those receiving active therapy (hazard ratio of 1.98, 95% CI 1.19–3.28). At study end, dual antiplatelet therapy was not associated with a signiﬁcant beneﬁt in preventing thrombosis. Similarly, administration of warfarin does not increase graft survival and is associated with signiﬁcant bleeding [40]. 3.6. Suicide. The incidence and prevalence of depression among dialysis patients is unknown but estimates vary from 20 to 50 percent [41]. Approximately one-fourth of dialysis patients are depressed at some point in time. Furthermore, about 1 percent of the dialysis patients commit suicide, International Journal of Nephrology especially the elderly population [42]. Risk factors for suicide include male gender, a preexistent psychiatric diagnosis, and addiction to drugs or alcohol [43–45]. Bleeding from a vascular access is rarely a result of a suicide attempt. 4. Conclusion In summary, patients with ESRD may lose blood from the AV ﬁstula due to a variety of reasons. Aneurysms should be considered a risk factor for acute vascular access bleeding in chronic dialysis patients and should never be cannulated. If assessed to be at risk for rupture, a workup for associated access infection should be considered and a surgical consult for aneurysm repair initiated. Dual antiplatelet therapy should be avoided in patients with AV ﬁstula aneurysms. Patient education is important to avoid complications of access bleeding; patients should be taught simple techniques like putting direct pressure to minimize bleeding while seeking acute medical care. Our patient should have applied direct pressure to his AV ﬁstula and called for emergency services, thus potentially reducing the duration of his hospitalization. Conﬂict of Interests The authors declared that there is no conﬂict of interest. References [1] Centers for Medicare & Medicaid Services (CMS) HHS, “Medicare and Medicaid programs; conditions for coverage for end-stage renal disease facilities. Final rule,” Federal Register, vol. 73, pp. 20369–20484, 2008. [2] Center for Medicaid and State Operations/Survey & Certiﬁca- tion Group: ESRD Interpretive Guidance Update, “Baltimore, MD: Department of Health Medicare and Medicaid Programs: Conditions for coverage for endstage renal disease facilities; ﬁnal rule: rules and regulations, Part II,” Tech. Rep. S&C-09- 01, Department of Health and Human & Human Services, Centers for Medicare & Medicaid Services, 2008. [3] W. D. Paulson and J. Work, “Controversial vascular access surveillance mandate,” Seminars in Dialysis, vol. 23, no. 1, pp. 92–94, 2010. [4] National Kidney Foundation, “KDOQI clinical practice guide- lines for vascular access, update 2006,” American Journal of Kidney Diseases, vol. 48, supplement 1, pp. S176–S247, 2006. [5] H. C. Diener, J. Bogousslavsky, L. M. Brass et al., “Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high- risk patients (MATCH): randomised, double-blind, placebo- controlled trial,” Lancet, vol. 364, no. 9431, pp. 331–337, 2004. [6] M. H. Usman, L. A. Notaro, R. Nagarakanti et al., “Combi- nation antiplatelet therapy for secondary stroke prevention: enhanced eﬃcacy or double trouble?” American Journal of Cardiology, vol. 103, no. 8, pp. 1107–1112, 2009. [7] P. A. Mennes, L. A. Gilula, and C. B. Anderson, “Complica- tions associated with arteriovenous ﬁstulas in patients under- going chronic hemodialysis,” Archives of Internal Medicine, vol. 138, no. 7, pp. 1117–1121, 1978. [8] “Hemodialysis vascular access and peritoneal dialysis access,” Contributions to Nephrology, vol. 142, pp. 193–215, 2004.