A rare and life-threatening case of spontaneous rupture of a right common femoral artery pseudoaneurysm is presented in a 69-year-old female with multiple comorbidities, including coronary artery disease, atrial fibrillation, and chronic kidney disease. The patient was on dual antiplatelet and anticoagulant therapy following a percutaneous coronary intervention (PCI) performed via right common femoral artery access one month earlier. She presented to the emergency department (ED) in a peri-arrest state with massive right thigh swelling and profound hypotension. Immediate resuscitation, massive transfusion, and multidisciplinary coordination led to stabilization and operative management. This case highlights the importance of maintaining a high index of suspicion for delayed vascular access complications in anticoagulated patients presenting with unexplained limb swelling and shock.
Pseudoaneurysm rupture, right common femoral artery, hypovolemic shock, PCI complication, anticoagulation, emergency resuscitation, thigh hematoma
The right common femoral artery remains a standard access site for coronary interventions. Although vascular access-site complications such as pseudoaneurysm formation are well recognized, delayed rupture presenting as life-threatening hemorrhage is exceedingly rare. The risk of rupture increases in patients receiving dual antiplatelet and anticoagulant therapy. The following case describes a delayed rupture of a right common femoral artery pseudoaneurysm occurring one month after PCI, presenting as hypovolemic shock.
A 69-year-old female was brought to the ED at 8:30 PM with sudden onset of severe right thigh pain and swelling. She also experienced non-bilious, non-bloodstained vomiting and altered sensorium during transit. At a nearby hospital, her blood pressure was 60/40 mmHg and she was in a peri-arrest state. One cycle of cardiopulmonary resuscitation (CPR) was administered, and noradrenaline infusion (15 ml/hr) was initiated before transfer to the tertiary center. She had reported right thigh pain for the preceding two days.
– Type 2 Diabetes Mellitus – Hypertension – Coronary Artery Disease – status post PCI to the left anterior descending artery (29/05/25) via right common femoral artery access; preserved LV function – Atrial Fibrillation with controlled ventricular rate – Chronic Kidney Disease (baseline creatinine: 1.5 mg/dL)
– Aspirin 75 mg OD – Ticagrelor 90 mg BD – Apixaban 2.5 mg BD (last dose on the morning of presentation)
A: Airway patent, no secretions B: Bilateral air entry present, SpO₂ 90% on 4L O₂ via face mask C: PR 102 bpm, cold peripheries, BP unrecordable, S1S2 present, no murmurs D: GCS E3V1M1, pupils 2 mm bilaterally, sluggishly reactive; CBG 572 mg/dL E: Large pulsatile swelling (15 × 15 cm) over right medial thigh at the site of prior femoral access
ABG: pH 6.86, HCO₃⁻ 5.5 Hb 4.4 g/dL, Hct <15% Na⁺ 127 mmol/L, Cl⁻ 95 mmol/L, Creatinine 2.9 mg/dL Lactate: 16.6 mmol/L ECG: Normal sinus rhythm, PR 91 bpm, RBBB Glucose: 572 mg/dL
After obtaining informed consent
A: Rapid sequence intubation with Etomidate (12 mg), Fentanyl (50 mcg), Vecuronium (4 mg)- Airway Secured with 7.5 ET tube fixed at 20 lip level . B: Mechanical ventilation: VC mode, TV 450 mL, PEEP 5, RR 14 C: Two large-bore IV cannulas inserted; 1L Ringer’s Lactate infused Right IJV central line inserted under ultrasound guidance Left radial arterial line placed (3 Fr) with opening BP 80/40 mmHg Massive Transfusion Protocol (MTP) initiated (1 PRBC : 1 FFP : 6 RDP) with additional 3 PRBCs via push-pull technique Noradrenaline titrated (10–15 ml/hr)
Foleys catheterization done
D : GCS : E1VTM1 , CBG : 572mg/dl
E : Temp : 98.7
Vascular Surgery, Interventional Radiology, Cardiology, ICU, Anesthesiology
CT Peripheral Angiography demonstrated:
– A pseudoaneurysm (1.8 × 1.4 cm) just proximal to the right common femoral artery bifurcation – A 3.5 mm pseudoaneurysm neck – A large hematoma (18.8 × 15 × 11 cm) in inter/intramuscular planes of medial proximal thigh – Active contrast extravasation from pseudoaneurysm into hematoma
The patient was stabilized with vasopressor and transfusion support and taken urgently for Right common femoral artery pseudoaneurysm repair and clot evacuation .
The common femoral artery is the most common site for iatrogenic pseudoaneurysm formation. Pseudoaneurysm at this site usually has long, narrow necks (<10 mm). The incidence of pseudoaneurysm formation is approximately 1% with diagnostic studies but increases to 3.2% when an interventional procedure is performed. After catheter removal, the reported average time of pseudoaneurysm onset varies from 5 to 6 days, with a late onset of 12 days. Koza and Kaya reported puncture-site pseudoaneurysm after 8.3 days (2–21 days) after intervention on average.
Oneissi et al. suggested (16 randomised control trials [RCTs] and 17 non-RCTs) that the overall incidence of puncture-site complications was 5.13% in RCT and 2.78% in non-RCT. The incidence of pseudoaneurysm was 0.23%–2.04% (mean: 0.61%) in RCT and 0.03%–3.23% (mean: 0.19%) in non-RCT. Puncture-site haematoma and bleeding are the most common complication followed by pseudoaneurysm in cases of endovascular intervention.Femoral artery pseudoaneurysm is a well-recognized complication following percutaneous femoral access. While most occur early in the post-procedure period, delayed rupture is rare but carries catastrophic consequences.
In this patient, triple antithrombotic therapy (aspirin, ticagrelor, and apixaban), along with comorbidities such as chronic kidney disease and atrial fibrillation, likely contributed to vascular wall fragility and spontaneous rupture. The absence of early warning signs and delayed onset posed a diagnostic challenge.
The patient’s profound hypovolemic shock necessitated rapid recognition, activation of a massive transfusion protocol, and multidisciplinary involvement, which proved lifesaving.
This case emphasizes:
– Vigilance for delayed access-site complications in anticoagulated post-PCI patients – Early CT angiography when pulsatile swelling of a limb is noted – The necessity of coordinated emergency, surgical, and transfusion support in such catastrophic vascular events
Delayed rupture of a femoral artery pseudoaneurysm is an uncommon yet life-threatening complication of femoral arterial access, particularly in patients receiving dual or triple antithrombotic therapy. Emergency physicians must maintain a high index of suspicion when encountering post-PCI patients with acute limb swelling and shock. Rapid imaging, aggressive resuscitation, and early surgical intervention are crucial for improving survival outcomes.
Yavuzer Koza 1, Ugur Kaya 2
Dr Avinash 2nd Year Resident, Emergency Room Medicine, Kauvery Hospital Chennai
Dr . Ashok nandagopal HOD , Department of Emergency Medicine, Kauvery Hospital, Alwarpet, Chennai.
