Arterial bleeding is a relatively common VAS complication where blood collects in the soft tissue. It is caused by blood loss at the VAS or by the perforation of an artery or vein and may occur if the arterial puncture is below the femoral bifurcation, making the femoral head unavailable to assist with compression.

Clinically, the skin surrounding the puncture site, where visible swelling is noticeable, is hardened. Hematomas vary in size and are often associated with pain in the groin area, which can occur at rest or with leg movement. Depending on severity, they can result in a decrease in hemoglobin and blood pressure and an increase in heart rate.

Managing a hematoma requires additional compression and immobilization of the leg, marking the area to evaluate for any change in size, providing hydration, monitoring serial complete blood cell counts, maintaining/prolonging bed rest, and stopping anticoagulant and antiplatelet medication if necessary, as well as blood transfusions if indicated.

If it is severe, it may require surgical evacuation but this is a rare occurrence in children. Many hematomas resolve within a few weeks as the blood dissipates and is absorbed into the tissue.

Pulse loss after cardiac catheterization has been reported to occur in infants weighing less than 14 kg despite prophylactic use of heparin. The cause is usually vasospasm, especially in smaller patients. The classical 5 Ps (pain, paralysis, paresthesias, pulselessness, and pallor) are indicative of impaired circulation.

Recognizing limb ischemia in infants may be delayed because of their inability to communicate and the presence of more subtle signs such as decreased skin temperature and range of motion and skin discoloration.

As return of palpable pulses can be a false indicator of vessel patency, a rapid check of vasospasm (versus VAS thrombosis) should be made by ultrasound.

Due to the children’s ability to develop a rich collateral network (Fig. 14.1), claudication or limb length discrepancy is less likely to occur.

Patients with markedly diminished pedal pulses at the end of catheterization should receive a heparin infusion at a rate of 12–17 units/kg/h to eliminate the risk of arterial spasm. This should begin with a bolus of 100 units/kg if the patients did not receive heparin during catheterization or of 50 units/kg if more than 2 h have elapsed after heparinization during the procedure. If the pedal pulse remains non-palpable or greatly diminished 4 h later, thrombolysis is considered and the patient should be transferred to the ICU. Thrombolysis instituted with tissue-type plasminogen activator using a bolus of 0.1 mg/kg followed by an infusion of 0.5 mg/kg/h for 2 h. Heparin infusion is then reinstituted at the same rate for 4 h.

If pulses become palpable during this period, heparin is continued for 6 h. Otherwise, a second course of thrombolysis is administered, again with a bolus of 0.1 mg/kg followed by an infusion of 0.5 mg/kg/h for 2 h with another subsequent heparin infusion of 12–17 units/kg/h for 6 h. Patients have to be closely observed for complications, particularly for bleeding at the VAS. It is important to expose the pressure dressing so that bleeding can be instantly recognized and treated with manual compression (MC). The patient is kept NPO and remains in the supine position with the leg kept straight. Vital signs are monitored closely. This can lead to a patency rate of the target vessel of 95 % [1].