a 57-year - old man ( height , 170 cm ; weight , 67 kg ) diagnosed with recanalized cerebral aneurysm of the left anterior communicating artery was scheduled to undergo gdc embolization . his glasgow coma scale score was 12 of 15 ( eye opening , 3 ; motor response , 5 ; verbal response , 4 ) . his coagulation profile was normal , and his hemoglobin level was 11.8 g / dl . the preinduction blood pressure and heart rate were 132/83 mmhg and 53 beats / min , respectively . after anesthetic induction of 4 g / ml ( effect - site concentration ) propofol and 2 ng / ml remifentanil by target - controlled infusion ( tci ) using an orchestra infusion pump system ( fresenius kabi , brezins , france ) , 50 mg rocuronium was administered to facilitate tracheal intubation . during embolization , the blood pressure and heart rate were maintained at 102 - 130/68 - 74 mmhg and 50 - 60 beats / min , respectively , with a tci of 3 g / ml propofol and 2 ng / ml remifentanil . the right femoral artery was cannulated with a 6 fr introducer sheath , and 3,000 iu heparin was administered intravenously to prevent thromboembolism . after the sheath for the gdc embolization procedure was removed , the femoral puncture site was closed with perclose , angioseal , and safe guard. after the anesthetics were discontinued , 0.4 mg glycopyrrolate and 1.5 mg neostigmine were administered for reversal of muscle relaxation . during emergence from anesthesia , with the endotracheal tube still in place , his blood pressure suddenly dropped to 51/23 mmhg , and his heart rate increased to 103 beats / min . then , 10 mg ephedrine and 500 ml hydroxyethyl starch were administered intravenously . the blood pressure increased transiently to 72/53 mmhg , but dropped again . for continuous monitoring of blood pressure , the patient could breathe spontaneously , but his conjunctiva was very anemic and his abdomen was rigid . the results of other laboratory tests were as follows : na level , 146 mmol / l ; k level , 3.9 mmol / l ; ph , 7.29 ; pco2 , 41.3 mmhg ; po2 , 416.5 mmhg ; base excess , -6.8 mmol / l ; creatine kinase - muscle and brain fraction ( ck - mb ) level , 0.2 iu / l ; and troponin level , < 0.01 ng / ml . no bleeding focus was detected at the femoral puncture site . abdominal sonography was performed to screen for intraperitoneal hematomas , but no specific finding was obtained . computed tomographic ( ct ) angiogram of the abdomen showed hematomas around the urinary bladder , liver , and spleen ( fig . 1 and 2 ) ; pseudoaneurysm between the right femoral artery and right inferior epigastric artery ; and active extravasation from the origin of the right inferior epigastric artery ( fig . the self - expandable stent for embolization of the bleeding site was inserted through the contralateral femoral artery ( fig . , the blood pressure and heart rate were maintained at 110 - 118/67 - 72 mmhg and 112 - 123 beats / min , respectively . the patient was under anesthesia for 4 h 20 min , during which 3,000 ml crystalloid , 1,000 ml colloid , and 2 units of packed rbcs were administered ; his urine output was 980 ml . he was extubated 9 h 30 min after the induction of anesthesia and was transfused with 3 additional units of packed rbcs . the abdominal ct scan at 7 days after the procedure showed a decrease in the size of the retroperitoneal hematoma . we present a case of retroperitoneal hemorrhage caused by unintentional arterial puncture during femoral artery cannulation . a retroperitoneal hematoma may be associated with femoral artery puncture irrespective of whether a closure device is used after the intervention . it can be caused by an inadvertent puncture of the posterior wall of the femoral or iliac artery during cannulation . multiple attempts to puncture the femoral artery or puncture points high above the inguinal ligament of the femoral artery may result in occult retroperitoneal bleeding . these reports probably explain the hemorrhage in our case , since multiple attempts were made to puncture the femoral artery , and the femoral artery was punctured above the level of the inguinal crease . even uncontrolled retroperitoneal bleeding may show initial clinical signs that are very subtle , leading to delayed diagnosis . relative hypotension and mild tachycardia that transiently improve with the administration of fluids should alert clinicians to the possibility of retroperitoneal hematoma , and warrant further investigation . ultrasonography of the abdomen and pelvis may aid in the detection of hematomas , but it can not help determine the cause . free fluid or blood in the retroperitoneum often flows into the abdominal or pelvic cavity , which can be detected as free abdominal fluid on an ultrasound scan . in our case , however , no abdominal fluid was identified on the sonogram . ct is a noninvasive , rapid , and highly sensitive imaging method , and a ct angiogram may show the site of bleeding along with the contrast outside the vessels , an indication for urgent treatment . active bleeding can be seen as extravasation of contrast material ; this was observed in our case as well . if the patient is hemodynamically stable with no evidence of ongoing bleeding , conservative management , such as careful monitoring , fluid resuscitation , blood transfusion , and normalization of coagulation factors , is recommended . embolization is rapidly replacing open surgery in the treatment of retroperitoneal bleeding caused by iatrogenic iliofemoral vessel injuries . open surgery is opted if the patient remains unstable despite adequate fluid and blood product resuscitation , or if interventional radiology is unsuccessful or unavailable . in our patient , we assumed that the sheath cannulated into the femoral artery might block the bleeding focus at the site of the right inferior epigastric artery . the ct scan performed immediately aided in the timely diagnosis of retroperitoneal hematoma , and thereafter , the conditions were appropriately managed by both anesthesiologists and neuroradiologists . in conclusion , anesthesiologists should be aware of the occurrence of retroperitoneal hemorrhage as a consequence of interventional procedures such as femoral arterial puncture . when on clinical suspicion , immediate imaging should be performed to determine the site and extent of the hematoma ; fluid and blood product resuscitation is also essential . the severity of retroperitoneal hemorrhage in our patient suggests the need for prompt intervention in such cases .
we present the case of a 57-year - old man who developed retroperitoneal hemorrhage due to unintentional arterial puncture during femoral artery cannulation for guglielmi detachable coil embolization . on emergence from anesthesia 
 , he developed severe hypotension . 
 computed tomographic angiogram of the abdomen showed retroperitoneal hematomas around the urinary bladder , liver , and spleen . because femoral artery cannulation is a common procedure for intravascular embolization in neuroradiologic procedures , clinicians should be aware of the development of severe hematomas as a consequence of femoral artery puncture .