Forensic issues in cases of fatal hemorrhage from arteriovenous dialysis access sites

Abstract

Angioaccess sites to enable repetitive vascular punctures for hemodialysis include temporary or permanent indwelling catheters, port access devices, autogenous vessels in native arteriovenous fistulas, or non-autogenous material in prosthetic arteriovenous grafts. While complications such as thrombosis and infection are well recognized, lethal hemorrhage is much less commonly encountered. In this paper, selected cases are reported to demonstrate the range of situations that may be encountered at autopsy, including hemorrhage from a catheter in a case of suicide, and hemorrhage from an arteriovenous fistula and an arteriovenous graft. Predisposing factors to hemorrhage include coagulation abnormalities due to anticoagulant therapy or to underlying renal failure, stenosis or obstruction that has resulted in increased intraluminal pressure, local sepsis, repeated trauma from venesection and hypertension. An approach to such cases should include careful evaluation of the medical history and death scene, with dissection at autopsy of catheters, grafts and fistulas to demonstrate the condition of anastomosis sites, and the presence or absence of ruptures, perforations, stenoses, and/or thromboses. Histologic sampling of autologous fistula walls and surrounding soft tissues may reveal evidence of sepsis.

Fatal Hemorrhage from an Arteriovenous Fistula

“…Early bleeding does not require major treatment in most cases (mostly repairing the anastomosis suture or treatment of a subcutaneous bleeding source). On the other hand, late bleeding can be fatal in the home environment . Late bleeding in patients with chronic renal failure is typically associated with coagulation disorders due to uremic thrombocytopenia, polypharmacy, or anticoagulant therapy.…”

“…Late bleeding in patients with chronic renal failure is typically associated with coagulation disorders due to uremic thrombocytopenia, polypharmacy, or anticoagulant therapy. Bleeding is also associated with stenosis or AVF obstruction due to thrombosis or fibro‐intimal hyperplasia leading to increased intraluminal pressure, local sepsis, or repeated trauma and hypertension .…”

Femoral Artery Pseudoaneurysm and Sudden Death

“…Unfortunately, anticoagulant therapy, sepsis, hypertension, and repetitive trauma from venesection all predispose to spontaneous hemorrhage from these sites. Suicidal cutting of shunt tubing has also been reported (6,7).…”

Biting Through an Arteriovenous Hemodialysis Graft: An Unusual Method of Suicide

“…However, CRF with anemia probably renders such patients more susceptible to the effects of blood loss. Therefore, the amount of extravasated blood may be less than would be expected for fatal hemorrhage in a healthy individual (11). Other authors have described suicides following disconnecting or severing of dialysis catheters (4,10,11) or incising of an AVF (9).…”

“…The suicide rate among dialysis patients is significantly higher than in the general population (4–7). There have been previous reports of individuals committing suicide by severing or disconnecting their vascular access sites with resultant hemorrhage (4,8–11); however, there has been no previous report of exsanguination following biting into a vascular access site.…”