Is a 4 x 9 inch dark bruise on the thigh 5 days after a femoral (percutaneous procedure involving the femoral artery) catheterization (cath) procedure in an adult patient with a history of cardiovascular disease a concern if there is no swelling or discomfort present?

Post-Femoral Catheterization Bruise Assessment

A 4" x 9" dark bruise on the thigh 5 days after femoral catheterization without swelling or discomfort is generally reassuring and does not require immediate intervention, but you must actively exclude pseudoaneurysm and assess for arterial compromise.

Immediate Assessment Required

You need to perform a focused vascular examination right now:

• Check bilateral pedal pulses and compare them to the contralateral leg 1, 2
• Measure systolic Doppler blood pressure in both legs - if the affected leg is <67% of the unaffected leg, this indicates significant arterial compromise requiring immediate intervention 2
• Palpate for a pulsatile mass at the catheterization site, as physical examination alone misses >60% of pseudoaneurysms 3
• Assess for expanding hematoma, which would require urgent evaluation 2

When This Bruise Pattern Is Acceptable

The absence of swelling and discomfort is favorable, as it suggests:

• No active bleeding or expanding hematoma - these would cause progressive swelling and pain 3
• No pseudoaneurysm - these typically present as pulsatile masses, though they can be clinically silent 3
• Intact arterial flow - limb ischemia would cause pain, pallor, and absent pulses 3, 1

Simple bruising (ecchymosis) is common after femoral catheterization and represents blood tracking through tissue planes from the puncture site 3. The 5-day timeframe is consistent with evolving hematoma without complication.

Critical Red Flags That Change Management

You must obtain urgent duplex ultrasound if any of these are present:

• Pulsatile mass at the catheterization site 3
• Diminished or absent pedal pulse compared to baseline or contralateral leg 3, 2
• Systolic blood pressure <67% of the unaffected leg 2
• New or progressive swelling 2
• Any pain, numbness, or weakness in the affected leg 3, 1
• Bruit over the groin (suggests arteriovenous fistula) 1

Pseudoaneurysm Considerations

Obtain duplex ultrasound if there is any clinical suspicion, as physical examination is unreliable 3:

• Pseudoaneurysms occur in 0.1-0.2% of diagnostic procedures and 3.5-5.5% of interventional procedures 3
• Pseudoaneurysms <2.0 cm can be managed conservatively with ultrasound follow-up at 1 month, as 61% resolve spontaneously within 7-52 days 3
• Pseudoaneurysms ≥2.0 cm that persist or recur require treatment with ultrasound-guided compression or thrombin injection 3
• 90% of pseudoaneurysms that will close spontaneously do so within 2 months 3

Risk Factors That Lower Your Threshold for Imaging

This patient may be at higher risk if they have 1, 4:

• Age ≥70 years, female sex, obesity (BMI ≥28), or small body surface area (≤1.6 m²) 1
• Hypertension, diabetes, renal failure, peripheral arterial disease 1, 4
• Received glycoprotein IIb/IIIa inhibitors during the procedure 1
• Larger catheter size (≥7F) or interventional procedure rather than diagnostic 3, 4

Recommended Management Algorithm

For this patient with no swelling or discomfort:

1. Perform focused vascular exam now - bilateral pedal pulses and Doppler pressures 1, 2
2. If pulses are symmetric and no pulsatile mass - reassure and provide return precautions 3
3. If any abnormality on exam - obtain duplex ultrasound immediately 3
4. Provide clear return precautions: come back immediately for new swelling, pulsatile mass, pain, numbness, weakness, or color changes in the leg 3, 1

Common Pitfall to Avoid

Do not assume a large bruise is benign based on size alone - the critical distinction is between simple ecchymosis (benign) and pseudoaneurysm (requires treatment). A 4" x 9" bruise can coexist with an underlying pseudoaneurysm that is clinically silent 3. The absence of symptoms is reassuring but not definitive - when in doubt, obtain duplex ultrasound 3.