Managing Iatrogenic Common Femoral Artery Hemorrhage in an Extracorporeal Membrane Oxygenation (ECMO) Patient When Standard Access Fails.

Iatrogenic injuries related to resuscitative efforts and emergent vascular access can be life-threatening, particularly in critically ill patients with limited treatment options. We present a case of a patient who collapsed due to an acute ST-elevation myocardial infarction and underwent prolonged resuscitation, which was complicated by hepatic injury likely secondary to chest compressions and injury to the left common femoral artery (CFA) following multiple arterial line attempts. The patient was referred for an angiogram evaluation primarily for suspected hepatic injury. Conventional femoral access was not feasible, as the right groin was occupied by emergent venoarterial extracorporeal membrane oxygenation (VA-ECMO) cannulation, and a femoral compression device had been applied to the left groin following failed arterial access. Therefore, hepatic angiography was performed via left transradial access and demonstrated no active hemorrhage. Given the history of difficult arterial femoral access, further interrogation of the left iliofemoral system was undertaken, revealing multiple sites of active bleeding from the left CFA. Given the patient's clinical instability and poor candidacy for surgical repair, an endovascular approach was pursued. However, the available covered stent system could not be advanced to the target from the radial access due to length limitations, necessitating an alternative strategy. Retrograde pedal access was obtained, allowing successful treatment of the injured CFA segment with restoration of hemostasis and preservation of distal perfusion. The patient experienced no recurrent bleeding, limb ischemia, or need for reintervention during the hospitalization. This case highlighted the spectrum of resuscitation-related iatrogenic injuries and underscores the importance of adaptable endovascular strategies when conventional access routes are not feasible.