What is the appropriate management for a patient who develops a groin hematoma seven days after femoral catheterization, especially if they are on anticoagulation?

Management of Groin Hematoma 7 Days Post Femoral Catheterization

Obtain duplex ultrasound imaging immediately to differentiate between a simple hematoma and a pseudoaneurysm, as physical examination alone misses more than 60% of catheter-related pseudoaneurysms, and management depends entirely on this distinction. 1, 2

Immediate Diagnostic Workup

• Duplex ultrasound is mandatory to determine if this represents a simple hematoma versus a pseudoaneurysm (characterized by "to-and-fro" flow pattern on color Doppler) 1, 2, 3
• Verify coagulation parameters immediately, particularly if the patient is on anticoagulation (check aPTT, INR, and antiplatelet agents) 2, 4
• Monitor distal limb perfusion with pulse oximetry on the affected foot to detect arterial compromise early 2, 4
• Assess for compressive symptoms: femoral nerve neuropathy (pain, numbness), venous thrombosis (leg swelling), or signs of retroperitoneal extension 2, 4

Management Algorithm Based on Ultrasound Findings

If Simple Hematoma (No Pseudoaneurysm)

• Conservative management with observation is appropriate for most simple hematomas without vascular injury 2
• Monitor for expansion, compressive symptoms, or development of pseudoaneurysm 2
• Surgical evacuation is indicated only if the hematoma is tense and causing compressive symptoms (nerve compression, venous obstruction) 2

If Pseudoaneurysm <2.0 cm

• Conservative management with observation is the preferred approach, as 61% resolve spontaneously within 7-52 days and only 11% ultimately require surgical intervention 1, 2, 4
• Re-evaluate with duplex ultrasound at 1 month after the original injury 1, 2, 4
• 90% of small pseudoaneurysms that close spontaneously do so within 2 months 1, 2
• This recommendation holds even if the patient is on anticoagulation, though closer monitoring may be warranted 1

If Pseudoaneurysm ≥2.0 cm

• Ultrasound-guided thrombin injection is the preferred initial treatment, achieving 93% aggregate success rate 2, 4
• Inject 100-3000 international units of thrombin under ultrasound guidance 2
• Rare complications include distal thromboembolism (<2% of cases) 2
• Surgical repair is indicated for pseudoaneurysms ≥2.0 cm that persist or recur after ultrasound-guided compression or thrombin injection 1, 2, 4

Urgent Surgical Indications (Regardless of Size)

Immediate surgical repair is necessary for any of the following:

• Rupture into retroperitoneal space or upper thigh 1, 2, 4
• Skin erosion or expanding rupture into adjacent soft tissue 1, 2, 4
• Venous thrombosis from compression of adjacent femoral vein 2, 4
• Painful neuropathy from femoral nerve compression 2, 4
• Infected femoral pseudoaneurysm (suspect if fever, erythema, or history of IV drug use) 1, 2, 4
• Active bleeding or hemodynamic instability 5

Special Considerations for Anticoagulated Patients

• Ultrasound-guided compression has a high failure rate (87.5%) in fully anticoagulated patients 5
• Consider ultrasound-guided thrombin injection or embolization as first-line interventions rather than compression therapy in anticoagulated patients 5
• Embolization was successful in all four anticoagulated patients in one series where compression failed 5
• Consult interventional radiology or vascular surgery before attempting any intervention in anticoagulated patients 2

Critical Pitfalls to Avoid

• Never rely on physical examination alone: A pulsatile mass may be absent even with significant pseudoaneurysm, and ultrasound is mandatory 1, 2, 3
• Do not prematurely intervene on small pseudoaneurysms (<2.0 cm): Most resolve spontaneously, and unnecessary procedures carry risk 1, 2, 4
• Watch for concealed retroperitoneal bleeding: Hemorrhage associated with femoral catheterization may extend into the retroperitoneum without obvious groin findings 2, 4
• Do not delay imaging in anticoagulated patients: These patients have higher complication rates and may require more aggressive intervention 5