Which of the following can cause a retroperitoneal bleed after femoral access?

• A. High femoral artery stick (above inguinal ligament)
• B. Low femoral puncture
• C. Radial artery access
• D. Brachial artery access

Answer: (A)

Puncture location relative to the inguinal ligament determines whether bleeding can track into the retroperitoneal space. If the arterial access is high—above the inguinal ligament—the needle or sheath enters the external iliac artery or higher. Bleeding in this area is retroperitoneal, where it can accumulate without obvious external signs and be difficult to control with simple compression.

That’s why a high femoral artery stick is the best answer here: it creates a conduit for a retroperitoneal hematoma, which can be life-threatening and hard to tamponade. In contrast, a low femoral puncture stays below the inguinal ligament in the femoral artery within the femoral sheath, so bleeding tends to form a groin hematoma that is more accessible to compression and local measures. Radial or brachial access involves upper-extremity vessels and does not involve the retroperitoneal space, so they do not cause retroperitoneal bleeding.