1. Femoral Access Site Bleeding Femoral access site bleeding is correlated with a longer hospitalization and higher rates of morbidity and mortality at 30 days post procedure, especially when transfusion is required.^2,5

The modified Seldinger technique is the most commonly used method of gaining femoral arterial access. Technical and anatomic precision are critical to minimizing the risk of bleeding. Arterial puncture should occur within the common femoral artery (CFA), below the inguinal ligament and above its bifurcation, directly over the middle one-third of the femoral head. Puncture at this site allows for manual compression against a noncompliant structure to achieve adequate hemostasis. Superficially, this location is approximately 1-2 cm below the inguinal ligament half way between the anterior superior iliac crest and the pubic symphysis. The inguinal skin crease should not be used as a landmark for arterial puncture as it is located below the femoral artery bifurcation in 70% of patients. Fluoroscopy is routinely used
to locate the femoral head and assist in guiding anatomically precise CFA cannulation. Care must also be taken to avoid puncture of the posterior wall of the femoral artery from which bleeding may be less readily apparent. The use of a micropuncture needle is generally preferred to reduce arterial trauma in case multiple attempts at access are needed.

2. Retroperitoneal Hemorrhage Retroperitoneal (RP) hemorrhage is a rare but dreaded complication of high femoral arterial puncture above the inguinal ligament and occurs in approximately 0.3%-0.8% of cases involving femoral arterial access.^2,6,7 The etiology is usually injury to a suprainguinal vessel or puncture of the posterior wall of the femoral or external iliac artery. Other than this, traditional risk factors include (1) female gender, (2) peripheral vascular disease, and (3) low body surface area.^4,6 RP hemorrhage has two potential manifestations. First, the hemorrhage may be contained within the fascia of the iliopsoas muscle, which can be associated with compression neuropathy involving the lumbar plexus. Second, the RP hemorrhage may occur within the space between the peritoneum and RP structures, which is large enough to accommodate life threatening amounts of blood loss (Fig. 19.2). One report classified the most common presenting signs and symptoms of RP hemorrhage in 26 patients, which were hypotension (92%), diaphoresis (58%), groin discomfort (46%), abdominal or flank pain (42%), bradycardia (31%), and back pain (23%).⁶ Bruising of the flanks, described as “Grey Turner” sign, or the umbilicus, known as “Cullen” sign is typically a late manifestation. Occasionally, RP bleeding can present as a “vagal” reaction with bradycardia and diaphoresis, typically thought of as a benign response to pain or sheath removal, but only transiently responsive to intravenous fluids and atropine. Noncontrast abdominal and pelvic computed tomography
scan is highly sensitive and specific for confirming the diagnosis and is also helpful in identifying possible hydronephrosis due to ipsilateral ureter or bladder compression. Successful management depends on early recognition, supportive care with intravenous fluids, blood products, and optimizing the coagulation and platelet profile is all that is usually required until hemostasis is naturally achieved. In uncommon cases of extreme hemodynamic consequence consideration should be given to urgent angiography with prolonged percutaneous balloon inflation at the arteriotomy site, use of a covered stent, or surgical exploration and direct repair of the arteriotomy site.

3. Radial, Brachial, and Distal Lower Extremity Access Site Hemorrhage Compared with femoral arterial access, rates of major bleeding (OR = 0.53), all-cause mortality (OR = 0.71), and major adverse cardiovascular events (OR = 0.84) are lower with radial arterial access in patients undergoing percutaneous coronary intervention according to a 2016 meta-analysis of over 22,000 patients.⁸ This is due to the radial artery’s smaller caliber and superficial course, limiting internal bleeding and allowing easy compression of external bleeding. Localized hematomas may require extended manual compression of the arteriotomy site, arm elevation, and application of ice. If unrecognized, however, hematoma formation within the wrist may spread briskly from local infiltration of the soft tissue to involvement of a significant portion of the forearm. Rarely, signs of vascular compromise including pain, pallor, paresthesia, and paralysis may ensue, signifying compartment syndrome and requiring surgical evacuation to prevent tissue necrosis and restore vascular integrity.

1. Diagnosis The history and physical examination may indicate the presence of an AVF. Most patients are asymptomatic, and the most common presenting sign is the presence of a palpable thrill or bruit heard on auscultation, or a pulsatile mass. Rarely, large fistulas with high shunt volumes may present with symptoms related to arterial insufficiency, venous hypertension, or high-output congestive heart failure.