In some cases in which the catheter has been placed recently, bleeding or oozing from the exit site while on dialysis, a sheath is present and eliminating the sheath resolves the oozing. It appears the channel through the sheath reaches the venotomy and into the tunnel…

When I have confirmed that bleeding is coming from the tunnel and not from the venotomy, I Identify the spot along the tunnel where the bleeding is coming from as described by Dr. Sequeira, and I insert a horizontal mattress suture with Prolene or Nylon and remove it two to three days later. This if a pressure dressing does not work. If the bleeding is from the exit site i use chemical cautery with - a Silver nitrate stick and remove excess Silver nitrate with a cotton swab or gauze then apply sterile pressure dressing.

Thats a good tip Alex.

Thats a good tip Alex.

Purse string suture around the exit site usually gets the job done. No bleeding, no phone calls, no dramsa. Often required for catheter exchanges

I agree with you David. I routinely place a purse string suture at the exit site. For exchanges, I try to go a little deeper trying to catch the fibrin sheath in the suture material. Haven't been called about bleeding in a long time.

Would there be a risk of exit site Infection with Purse String Suture? Will the risk be higher if blood in the tunnel?

I do worry about an increased risk of exit site infection although I cannot say that the concern is valid. That being said, there is an increased incidence of infection amongst exhanged catheters in general

I agree with purse string suture. I place a 4-O Vicryl purse string suture at the exit site of all of the catheter patients (insertions and exchanges). It is absorbable but closes the tunnel in case of bleeding and holds the catheter cuff within the tunnel if the external segment of the catheter gets tugged on at least long enough for tissue ingrowth. Although in my experience it is extremely rare to have significant bleeding from the tunnel (I typically see it in new ESRD patients with coagulpathy or if on OACs), I typically take a 4x4 and insert an end of it up the tunnel from the exit site after I have tunneled the catheter and leave it there while I finish the case (for insertions). If this doesn't cause hemostasis, I have inserted gel foam up the tunnel then placed my purse string suture. I can't think of any cases where that wasn't enough intervention. Bharat -- I've been using the purse string suture at the exit site for over 20 years and cannot think of any cases that we could attribute the suture to infection.

I haven't seen much in the way of exit sit infections, but do exchange through the same tunnel only in a select group of patients. If I have any concern about infection, I'll make a new tunnel and occasionally a new puncture.
The stitch doesn't need to stay long

I haven't seen much in the way of exit sit infections, but do exchange through the same tunnel only in a select group of patients. If I have any concern about infection, I'll make a new tunnel and occasionally a new puncture.
The stitch doesn't need to stay long

I use plain gut suture as it is rapidly absorbed. I reserve the purse string for exchanges or primary placements where there is bleeding

I use plain gut suture as it is rapidly absorbed. I reserve the purse string for exchanges or primary placements where there is bleeding

I hate to be contrarian, but I have never placed a purse string around the exit site. I have seen plenty, however, from my local hospital that are red/inflamed/crusted because no one removes it in a timely fashion. We place a nice dressing that puts light pressure over the tunnel after placement (new and exchanges), and that seems to do the trick for us. In the very unusual instance of late bleeding, I have yet to see a case that didn't stop after 10-15min of manual pressure directly over the tunnel with the fingertip creating light pressure on the venotomy site. The problem there is finding someone to do it. I usually find these patients with massive dressing on top of dressing. I take the whole thing off and usually find the "pressure dressing" isn't actually placing any pressure over the tunnel. I know it is old fashion, but nothing beats manual pressure in my book - constant pressure, no peaking, etc...

I agree that the pursestring can have adverse effects on the surrounding tissue. It needs to be tight enough to achieve hemostasis, but not tight enough so as to cause necrosis. It's a fine line !

I support and teach NOT using a pursestring at the exit site routinely due to their frequently not getting removed and mu unproven belief that they contribute to colonization (much like we avoid putting an exit site stitch on a PD cath). I do use a Biopatch routinely (which has nothing to do with bleeding obviously). One helpful trick is to inject the exit site with lido/epi to cause vasoconstriction while you hold pressure. And elevate stretcher 45 degrees to lower venous pressure

On a slightly different note I would like ask the group how many of you insist on holding plavix or asa before inserting or exchanging a catheter. I have always places them without stopping the medication and really have not encountered any major issue. A new group of IR docs in our hospital decline to place tunneled caths unless these meds are held and when questioned they quote that these are SIR guidelines. Do we have ASDIN guidelines on this and if not should we create them. As nephrologists doing 2 procedures seems not fair to our pts.

I never hold antiplatelet agents for any procedure, particularly non-incisional. I request a number of blocks for my fistula creations, and my anesthetists don't squawk about holding aspirin for interscalene blocks. They probably do for spinals.
Also, INRs below 2.5 don't seem to be a problem, even for open procedures

At MGH we tracked our patients with tunneled dialysis catheter & tunneled small bore catheter placements that were on ASA & plavix for over a year. We did not have any patients that had bleeding from the tunnel exit site or venotomy site so we do not hold ASA or antiplatelet therapy for our patients for placement or removal.

Here’s the data - however getting your doctors to read and accept this can be challenging:

https://journals.sagepub.com/doi/pdf/10.5301/jva.5000586

I couldn't attach the PDF directly, but you can access it through your ASDIN membership - ASDIN JVA access is available here - https://www.asdin.org/general/custom.asp?page=JVATPS.

I think SIR guidelines from 2019 states dialysis access interventions are low bleeding risk and recommend now withholding ASA/Plavix or even AC. https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext#secsectitle0085

Sayee is correct. If they’re quoting SIR guidelines, they’re using older SIR guidelines. Tunneled catheters are now low risk, and thus do NOT need to hold AC or correct INR <3.