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Femoral pseudoaneurysm and access complications after catheterisation

A femoral pseudoaneurysm after catheterisation is a hole in the arterial wall through which blood fills a cavity surrounded by tissue — a pulsatile mass with a bruit in the groin; diagnosis is by duplex, a small pseudoaneurysm may close by itself, the preferred treatment for most others is ultrasound-guided thrombin injection, and surgery is kept for infection, rapid growth, skin compromise or failure.

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Why it matters in the exam

Femoral access complications are more frequent with a puncture that is too low (into the SFA or profunda instead of the common femoral artery), large sheaths, anticoagulant and antiplatelet therapy, obesity and inadequate compression after sheath removal. The patient complains of groin pain and swelling, and on examination there is a pulsatile mass with a bruit. Duplex shows a cavity with swirling ("yin-yang") flow and a neck in which flow goes in and out. A small pseudoaneurysm (up to about 2–3 cm) without symptoms may close by itself, so it can be observed with repeat duplex. For a larger or symptomatic pseudoaneurysm, ultrasound-guided thrombin injection into the cavity is the first treatment, with high success (above 90%) and little pain; an older alternative is ultrasound-guided compression, which is painful and less effective. A possible complication of thrombin is embolism to distal arteries, so caution is needed with a wide, short neck.

Surgery (direct repair of the arterial hole) is required for an infected pseudoaneurysm, rapid growth or bleeding, tense or necrotic skin over the mass, nerve compression, failed thrombin, and a significant arteriovenous fistula. Another dangerous complication is retroperitoneal haematoma: a puncture too high, above the inguinal ligament, cannot be compressed, and blood collects behind the peritoneum — the patient develops hypotension, tachycardia and flank or back pain, sometimes without groin swelling. Diagnosis is by CT, and treatment: stopping anticoagulation as far as possible, resuscitation with fluids and blood, and for ongoing bleeding — a covered stent or surgery. Other complications: arteriovenous fistula (continuous bruit), dissection and arterial thrombosis with leg ischaemia. Prevention: puncture of the common femoral artery over the femoral head, guided by ultrasound or fluoroscopy.

In any patient with hypotension after groin catheterisation, retroperitoneal bleeding must be considered, even when the groin looks quiet.

Key points

• Pulsatile mass with a bruit — duplex.
• Small — observation.
• Large — ultrasound-guided thrombin.
• Infection or necrosis — surgery.
• Hypotension — think of retroperitoneal bleeding.

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Sources

• Rutherford's Vascular Surgery and Endovascular Therapy, 10th edition (2022) — Iatrogenic arterial injuries and pseudoaneurysms
• Sabiston Textbook of Surgery, 21st edition (2022) — Arterial injuries and access complications

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.