CathLabHub complications toolkitcathlabhub.com/toolkit/retroperitoneal-hemorrhageIn review, October 24, 2026
Recognize
The signs on the monitor, the image and the patient.
- MonitorHypotension and diaphoresis, often with bradycardia, during or within the first 3 hours after the case 12.
- PatientLower abdominal, flank, back or groin pain; suprapubic tenderness; flank or umbilical bruising late 12.
- ImageBladder displaced to one side on fluoroscopy (dented bladder) after contrast; extravasation above the femoral head on angiography 1.
- LabA hemoglobin that falls, often later than the pressure 1.
- PatientA transient response to fluids 2.
Act now
In the order the operator does them. The first three come first, whatever else is happening.
- Suspect it in every hypotensive patient after femoral access, even with a closure device 1.
- Large bore IV access, fluids, type and cross, hemoglobin 1.
- Call for help: the operator, and vascular surgery now 2.
- Reverse anticoagulation once the diagnosis is made: protamine for heparin, stop glycoprotein IIb/IIIa inhibitors and cangrelor 1.
- In the lab: fluoroscopy of the bladder, then contralateral femoral access and angiography of the bleeding side 1.
- Active bleeding: inflate a balloon across the hole at low pressure 1.
- Large vessel hole: covered stent; small branch such as the inferior epigastric: coils 1.
- Failure, or a hole at the femoral bifurcation: surgery 1.
- Outside the lab and stable: CT of the abdomen and pelvis; unstable: straight to the lab or the operating room 1.
Equipment
From the complications cart. Linked items open in the equipment directory.
- Crossover sheath from the other groinDirectory: Pinnacle Destination guiding sheath.
- Peripheral balloons for tamponadeDirectory: Armada 35, Mustang.
- Covered stentsBalloon expandable for precise placement; self expanding in the common femoral artery, which flexes 1. Directory: Viabahn VBX, Viabahn.
- Coils or a vascular plug for a small branchDirectory: MVP micro vascular plug.
- Stiff 0.035 inch and hydrophilic wiresDirectory: Amplatz Super Stiff, Glidewire.
Drugs
Adult doses as the cited source gives them. Check your formulary and the label.
- ProtamineReverse heparin once the diagnosis is made 1.Weight based dose in the Cath Med App
- Glycoprotein IIb/IIIa inhibitor, cangrelorStop 1.Weight based dose in the Cath Med App
- Normal saline and bloodSeveral liters of saline may be needed; transfuse by the bleeding and the hemodynamics 1.
- Atropine0.5 mg IV, repeat to 3 mg, for the vagal bradycardia 3.
Who to call
The escalation ladder, first call first.
- Operator and second operator: one for contralateral access, one for resuscitation.
- Vascular surgery: at once, for repair if endovascular sealing fails 21.
- Blood bank: type and cross, activate massive transfusion if needed.
- Interventional radiology: for coils in a small branch.
- Rapid response or ICU: for monitoring after control.
The bailout step by step
Contralateral balloon tamponade and covered stent 1
- Contralateral common femoral access; crossover sheath over the aortic bifurcation.
- Angiogram of the bleeding iliofemoral segment to find the hole.
- Wire across the hole into the superficial femoral artery.
- Inflate a peripheral balloon sized to the vessel at low pressure across the hole; confirm the leak stops.
- Hold for several minutes; if bleeding persists, deploy a covered stent across the hole.
- Small branch bleed: select the branch with a microcatheter and coil it, after excluding back bleeding.
- Completion angiogram; check the distal pulses.
Prevent
After care and documentation
- ICU or step down monitoring; serial hemoglobin.
- Most stabilize without surgery once anticoagulation is stopped 2.
- Document the puncture site, the bleeding site, the transfusions and the repair.
Practice
Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.
References
- Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 29, Vascular access complications.
- Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
- Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
- Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. J Am Coll Cardiol 2022;79:e21-e129.
- CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).
Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/retroperitoneal-hemorrhage. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.