Teaching Case

Description of a technique to perform a purse string suture to control bleeding after dialysis access interventions

Due to short subcutaneous channels and thin vascular walls, bleeding control after percutaneous interventions in hemodialysis fistulas and grafts can be considerably prolonged especially with introduction systems of 8 F and larger. To facilitate bleeding control after percutaneous interventions in dialysis shunts and grafts, a simple subcutaneous purse string suture can be very helpful. This simple suture which must not touch the vein or graft itself, works because the subcutaneous layer in puncture areas is mostly scarred due to repeat puncture of the access. Thus, the blood cannot easily spread within the subcutaneous tissue. The purse string suture compresses the puncture channel and works reliably in most cases. Even if still bleeding occurs, slight compression can be added. It definitely shortens the bleeding time and in most cases it causes immediate cease of bleeding. It is very important not to perform the suture on the vessel itself but only on the subcutaneous layer.

Failure can occur if the suture is performed against the direction of puncture, if applied in virgin areas where no previous punctures have been performed and in immature or recently created accesses and grafts. Under those instances, additional compression is necessary. After performing the suture, normally no compression is performed which is helpful to keep the shunt flow undeteriorated.