Forensic issues in cases of fatal hemorrhage from arteriovenous dialysis access sites
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CASE REPORT
Forensic issues in cases of fatal hemorrhage from arteriovenous dialysis access sites Roger W. Byard Æ Ross A. James
Accepted: 9 January 2007 / Published online: 10 July 2007 Humana Press Inc. 2007
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.
Keywords Catheter Arteriovenous fistula Graft Chronic renal failure Dialysis Hemorrhage Sudden death Forensic pathology
R. W. Byard (&) Discipline of Pathology, The University of Adelaide, Frome Road, Level 3 Medical School North Building, Adelaide 5005, Australia e-mail: [email protected]
Case reports
R. W. Byard R. A. James The University of Adelaide, Forensic Science SA, Adelaide, Australia
Introduction In 1998 approximately 320,000 patients in the United States had end-stage renal disease of whom 72% were undergoing regular hemodialysis [1]. Access sites for hemodialysis include indwelling venous catheters, arteriovenous fistulas and arteriovenous grafts. Given the number of such cases in the community, their discovery at autopsy is surprisingly uncommon. This is possibly due to the chronic nature of the underlying condition and the fact that many individuals with end-stage renal failure may not come to the coroner’s or medical examiner’s attention as their clinical status and diagnosis are well known, and death is often anticipated. While a number of complications may occur at hemodialysis access points, the majority are not life threatening. We report a series of representative cases, involving a catheter, a fistula and a graft, to demonstrate the rare complication of lethal exsanguinations from angioaccess sites in chronic renal failure, and to provide an overview of the features of these cases that may be encountered at autopsy.
Case 1 A 45-year-old woman with a h
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