To the editor: The use of central venous catheters for temporary vascular access in hemodialysis may occasionally

result in arterial puncture.1 Nevertheless, the frequency of clinically significant arterial damage after femoral

catheterization in hemodialysis is low. Such damage may give rise to thrombosis, bleeding, pseudoaneurysms or arteriovenous fistulas.2-4 We describe a case of delayed presentation of a right femoral arterial pseudoaneurysm following failed venous catheterization for hemodialysis. To our knowledge, only one similar case has been reported to date.2



A 41-year-old male was admitted with advanced chronic renal failure of indeterminate origin. The personal history

included poorly controlled arterial hypertension and dyslipidemia. The start of renal replacement therapy was

required. Ultrasound was used to identify the anatomical relationship between the femoral artery and vein. In both

extremities the vein was located posterior to the artery, except over a short trajectory in the region of the inguinal

fold, where it was found to be positioned slightly medial. Arterial puncture was observed on one attempt, as a result

of which compression was applied and the left femoral vein was finally catheterized. Dialysis without anticoagulation

was started in the first two sessions. After 48 hours, and following normal inguinal exploration findings, low molecular weight heparin was resumed as antithrombotic prophylaxis, with doses adjusted to renal function. A few days later during a week-end, the patient participated in a race despite indications to avoid such activities. Twenty days after catheterization he developed sudden right inguinal pain. Inguinal exploration revealed a hard and pulsatile mass with a slight murmur and intense pain in response to palpation. The peripheral pulses were  preserved. Right femoral artery Doppler ultrasound confirmed the presence of a 17-mm right pseudoaneurysm. Initial treatment included strict bed rest with an inguinal compressive bandage. However, one week later the pseudoaneurysm was seen to have increased to 21 mm in size, with persistence of the pain. Aneurysm intracavitary thrombin injection under ultrasound guidance was thus performed (100 IU). This resulted in thrombosis of the pseudoaneurysm, without evidence of recurrences on occasion of the posterior ultrasound controls.



An arterial pseudoaneurysm is a pulsatile hematoma resulting from traumatic dissection of the arterial wall, creating

a communication between the vascular lumen and the surrounding tissue, with the extravasation of arterial blood. The use of anticoagulants, poorly controlled arterial hypertension, vasculopathy (arteriosclerotic or of an infiltrative nature), and even the technique and arterial trajectory used for puncture can give rise to such pseudoaneurysms.

5-7 The clinical suspicion is established 6-48 hours after arterial puncture, with the identification of a painful, pulsatile mass in the inguinal zone.7 In our patient, the administered low molecular weight heparin facilitated the delayed presentation of the complication, which was triggered by walking. Doppler ultrasound is the diagnostic technique of choice, and is moreover able to evaluate the evolution of the size of the lesion. Although surgical repair may prove necessary in cases where there is a risk of severe bleeding or limb ischemia, conservative

management is initially recommended. Strict bed rest, the suspension of anticoagulation, and compression applied manually in the form of an inguinal bandage or guided by ultrasound over the aneurysmal neck can resolve over 75% of all cases.5,7 The intra-aneurysmal injection of procoagulating substances such as thrombin represents a treatment option allowing immediate resolution without the need to suspend anticoagulation ¿ though it is not without side effects (generally of an anaphylactic nature).6



It is difficult to prevent complications of this kind, considering the technique employed and the antithrombotic

indications of our patients. However, compression and prolonged repose after iatrogenic arterial puncture, and the identification and early management of the complications are critical considerations for avoiding traumatic lesions with significant clinical repercussions.