Images and Case Reports in Interventional Cardiology Retroperitoneal Hematoma After Diagnostic Coronary Angiography Caused by Collateralization of a Chronic Common Femoral Artery Occlusion Secondary to Childhood Femoral Cannulation

A 52-year-old woman presented for investigation of exertional chest pain. Her medical history included an atrial septal defect; this was extensively investigated with right and left heart catheterizations at 13 years. There were complications related to this investigation, and further details were unavailable. The atrial septal defect was surgically repaired at 15 years; she had a subarachnoid hemorrhage, resulting in clipping of a middle cerebral artery aneurysm in 1999. She had bilateral inguinal scarring with normal femoral pulsation and distal limb pulsation; physical examination was otherwise unremarkable. She was a current smoker, and her total cholesterol level was 5.6 mmol/L (low-density lipoprotein, 3.8 mmol/L). Resting ECG showed a sinus rhythm with partial right bundle branch block and T-wave flattening in leads V2 through V6. Transthoracic echocardiogram was normal. Exercise stress testing with a standard Bruce protocol resulted in 2 mm of inferolateral ST-segment depression in Stage 2 (7 METS). In light of these results, she came forward for elective coronary angiography. The procedure was undertaken by means of a right femoral artery approach. The vessel puncture was unremarkable, and the wire passed without resistance. However, there was marked hypotension and bradycardia. Hemodynamic stability was achieved after the intravenous administration of 0.5 mg atropine and 500 mL 0.9% normal saline bolus. The procedure was abandoned and apparent hemostasis was achieved by manual pressure with no evidence of local hematoma or active bleeding. One hour after procedure, the patient complained of right iliac fossa pain requiring 7.5 mg of intravenous diamorphine for analgesia. Her observations remained stable, and abdominal examination was normal. A full blood count revealed a drop in hemoglobin concentration from 12.6 to 8.3 g/dL. Abdominal computed tomography revealed a large retroperitoneal hematoma extending from the right peripelvic area with compression of the right femoral artery. Following consultation with the vascular surgery team, a decision was made to aim for percutaneous treatment of the bleeding. An angiography was performed through the left femoral artery, and it demonstrated a well-collateralized chronic subtotal occlusion of the right common femoral artery (Figure 1). Selective catheterization of the right interFigure 1. Digital subtraction angiogram of the right femoral artery. There is subtotal occlusion of the CFA that is well collateralized (Col). The collaterals run from the EIA to the FB below the inguinal ligament. The distal vessels are normal. CFA indicates common femoral artery; EIA, external iliac artery; FB, femoral bifurcation.