{"id":10556,"date":"2025-09-13T13:21:40","date_gmt":"2025-09-13T13:21:40","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-journal\/?p=10556"},"modified":"2025-09-15T09:29:52","modified_gmt":"2025-09-15T09:29:52","slug":"delayed-spontaneous-rupture-of-right-common-femoral-artery-pseudoaneurysm-following-pci-a-rare-cause-of-hypovolemic-shock-in-an-anticoagulated-patient","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-september-2025\/delayed-spontaneous-rupture-of-right-common-femoral-artery-pseudoaneurysm-following-pci-a-rare-cause-of-hypovolemic-shock-in-an-anticoagulated-patient\/","title":{"rendered":"Delayed Spontaneous Rupture of Right Common Femoral Artery Pseudoaneurysm Following PCI: A Rare Cause of Hypovolemic Shock in an Anticoagulated Patient"},"content":{"rendered":"

[vc_section][vc_row][vc_column][vc_column_text]<\/p>\n

Abstract<\/h2>\n

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.<\/p>\n

Keywords<\/h2>\n

Pseudoaneurysm rupture, right common femoral artery, hypovolemic shock, PCI complication, anticoagulation, emergency resuscitation, thigh hematoma<\/p>\n

Introduction<\/h2>\n

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.<\/p>\n

Case Presentation<\/h2>\n

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.
\nShe had reported right thigh pain for the preceding two days.<\/p>\n

Past Medical History<\/h2>\n

– Type 2 Diabetes Mellitus
\n– Hypertension
\n– Coronary Artery Disease \u2013 status post PCI to the left anterior descending artery (29\/05\/25) via right common femoral artery access; preserved LV function
\n– Atrial Fibrillation with controlled ventricular rate
\n– Chronic Kidney Disease (baseline creatinine: 1.5 mg\/dL)<\/p>\n

Regular Medications<\/h3>\n

– Aspirin 75 mg OD
\n– Ticagrelor 90 mg BD
\n– Apixaban 2.5 mg BD (last dose on the morning of presentation)<\/p>\n

Primary Survey in ED<\/h3>\n

A: Airway patent, no secretions
\nB: Bilateral air entry present, SpO\u2082 90% on 4L O\u2082 via face mask
\nC: PR 102 bpm, cold peripheries, BP unrecordable, S1S2 present, no murmurs
\nD: GCS E3V1M1, pupils 2 mm bilaterally, sluggishly reactive; CBG 572 mg\/dL
\nE: Large pulsatile swelling (15 \u00d7 15 cm) over right medial thigh at the site of prior femoral access<\/p>\n

Investigations<\/h3>\n

ABG: pH 6.86, HCO\u2083\u207b 5.5 Hb 4.4 g\/dL, Hct <15%
\nNa\u207a 127 mmol\/L, Cl\u207b 95 mmol\/L, Creatinine 2.9 mg\/dL
\nLactate: 16.6 mmol\/L
\nECG: Normal sinus rhythm, PR 91 bpm, RBBB
\nGlucose: 572 mg\/dL<\/p>\n

Resuscitation<\/h3>\n

After obtaining informed consent<\/p>\n

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 .
\nB: Mechanical ventilation: VC mode, TV 450 mL, PEEP 5, RR 14
\nC: Two large-bore IV cannulas inserted; 1L Ringer\u2019s Lactate infused
\nRight IJV central line inserted under ultrasound guidance
\nLeft radial arterial line placed (3 Fr) with opening BP 80\/40 mmHg
\nMassive Transfusion Protocol (MTP) initiated (1 PRBC : 1 FFP : 6 RDP) with additional 3 PRBCs via push-pull technique
\nNoradrenaline titrated (10\u201315 ml\/hr)<\/p>\n

Foleys catheterization done<\/p>\n

D : GCS : E1VTM1 , CBG : 572mg\/dl<\/p>\n

E : Temp : 98.7<\/p>\n

Specialist Involvement<\/h3>\n

Vascular Surgery, Interventional Radiology, Cardiology, ICU, Anesthesiology<\/p>\n

Imaging<\/h3>\n

CT Peripheral Angiography demonstrated:<\/p>\n

– A pseudoaneurysm (1.8 \u00d7 1.4 cm) just proximal to the right common femoral artery bifurcation
\n– A 3.5 mm pseudoaneurysm neck
\n– A large hematoma (18.8 \u00d7 15 \u00d7 11 cm) in inter\/intramuscular planes of medial proximal thigh
\n– Active contrast extravasation from pseudoaneurysm into hematoma<\/p>\n

\"Delayed<\/figure>\n

Outcome<\/h3>\n

The patient was stabilized with vasopressor and transfusion support and taken urgently for Right common femoral artery pseudoaneurysm repair and clot evacuation .<\/p>\n

Discussion<\/h2>\n

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\u201321 days) after intervention on average.<\/p>\n

Oneissi\u00a0et al<\/em>. 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%\u20132.04% (mean: 0.61%) in RCT and 0.03%\u20133.23% (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.<\/p>\n

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.<\/p>\n

The patient\u2019s profound hypovolemic shock necessitated rapid recognition, activation of a massive transfusion protocol, and multidisciplinary involvement, which proved lifesaving.<\/p>\n

This case emphasizes:<\/p>\n

– Vigilance for delayed access-site complications in anticoagulated post-PCI patients
\n– Early CT angiography when pulsatile swelling of a limb is noted
\n– The necessity of coordinated emergency, surgical, and transfusion support in such catastrophic vascular events<\/p>\n

Conclusion<\/h2>\n

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.<\/p>\n

References<\/h2>\n
    \n
  1. Webber GW, et al. Pseudoaneurysm Formation after Arterial Puncture. J Vasc Interv Radiol. 2007.
    \nKassem MM, et al. Delayed Femoral Artery Pseudoaneurysm Rupture in Anticoagulated Patients: A Rare but Fatal Complication. Vasc Med. 2020.
    \n3. Lin PH, et al. Access site complications after femoral artery catheterization. J Cardiovasc Surg. 2013.
    \n4. Stabile E, et al. Bleeding complications in PCI: Role of triple antithrombotic therapy. Am J Cardiol. 2015.<\/li>\n
  2. https:\/\/journals.lww.com\/onsonline\/fulltext\/2020\/10000\/access_site_complications_in_transfemoral.2.aspx<\/a><\/li>\n
  3. Retrospective Analysis of 120 Cases of Iatrogenic and Traumatic Peripheral Arterial Pseudoaneurysms<\/li>\n<\/ol>\n

    Yavuzer Koza 1, Ugur Kaya 2<\/p>\n

    \n
    \"\"<\/div>\n
    \n

    Dr Avinash
    \n2nd Year Resident, Emergency Room Medicine,
    \n    Kauvery Hospital Chennai<\/a><\/b><\/p>\n<\/div>\n<\/div>\n

    \n
    \"\"<\/div>\n
    \n

    Dr . Ashok nandagopal
    \nHOD , Department of Emergency Medicine,
    \n    Kauvery Hospital, Alwarpet, Chennai.<\/a><\/b><\/p>\n<\/div>\n<\/div>\n

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