Alternative to the finger in the dike: use of the vascular closure button to control postdialysis bleeding in a haemodialysis access conduit.

OBJECTIVE: The purpose of this case series is to describe the application of a vascular closure button (VCB) for the repair of haemodialysis access bleeding. The VCB's main function is not to assist in bleeding control, but instead to provide easy access for removal of tightly placed sutures in the repair. METHODS: A retrospective review of patients undergoing ED repair of persistent bleeding from puncture sites in haemodialysis access conduits (HACs) using a VCB was conducted. Study patients were collected from ED visits to Our Lady of Lourdes Medical Center in Camden, New Jersey, USA, between May 2013 and August 2017. Patients were followed until the time of definitive repair of the underlying pathology or until the end of the study period. RESULTS: Seventeen VCBs were used to control persistent bleeding from HACs in the ED. Sixteen bleeds were the result of recent haemodialysis punctures, while one was from a bleeding site ulcer. All repairs were successful at controlling the bleeding with preserved HAC function in the ED and no delayed thrombosis. Follow-up time ranged from 1 day to 778 days. CONCLUSION: Vascular control buttons provide an effective means to control HAC postdialysis bleeding and allow for ease of suture removal without disruption of a repair with no long-term complications.

A patient with a large pulmonary saddle embolus eluding both clinical gestalt and validated decision rules.

We report a patient with chest pain who was classified as having low risk for pulmonary embolism with clinical gestalt and accepted clinical decision rules. An inadvertently ordered D-dimer and abnormal result, however, led to the identification of a large saddle embolus. This case illustrates the fallibility of even well-validated decision aids and that an embolism missed by these tools is not necessarily low risk or indicative of a low clot burden.