Concurrent femoral artery pseudoaneurysm and arteriovenous fistula following catheter ablation treated with selective coil embolization.

Iatrogenic femoral pseudoaneurysms and arteriovenous fistulas are uncommon but clinically significant complications of femoral access procedures. Simultaneous occurrence of both lesions is rare and poses diagnostic and therapeutic challenges. Multimodal imaging plays a critical role in defining lesion anatomy, hemodynamics, and selecting appropriate management. A 63-year-old male with a complex cardiac history, including mechanical aortic valve replacement, underwent catheter ablation for persistent atrial flutter via bilateral femoral venous access. Seven days postprocedure, he presented with progressive left groin pain, swelling, and ecchymosis. Duplex ultrasound revealed a pseudoaneurysm arising from a superficial femoral artery branch with arterialized venous flow within the adjacent femoral vein, consistent with a high-flow arteriovenous fistula. These findings were suggestive of a through-and-through vascular injury. Computed tomography angiography further delineated the arterial supply and confirmed early venous opacification of the adjacent femoral vein. Given the small pseudoaneurysm sac, an initial attempt at ultrasound-guided thrombin injection was performed; however, persistent high-flow shunting prevented successful thrombosis. Definitive treatment was achieved with selective transarterial coil embolization of the feeding branch, resulting in immediate angiographic occlusion and complete clinical resolution on follow-up imaging. This case underscores the importance of recognizing dual arterial and venous injury patterns in imaging and highlights the role of selective endovascular embolization when thrombin injection alone is insufficient. Early, comprehensive imaging assessment enables tailored minimally invasive management of complex femoral access complications.