Behind the Flank Pain: Unmasking Unusual Cause of Late Retroperitoneal Bleeding after Femoral Angiogram

Retroperitoneal hemorrhage is a rare but life-threatening complication of femoral arterial access during coronary angiography. We report a 73-year-old hypertensive, non-diabetic woman with prior coronary artery bypass grafting (CABG) (2013) and mild aortic stenosis, who underwent pre- aortic valve replacement (AVR) coronary angiography. Two hours post-procedure, she developed hypotension responsive to fluids; at 3 h, she reported hypotension with acute abdominal pain. Bedside ultrasound revealed a 12 × 6 × 6 cm perirenal hematoma. Computed tomography aortogram showed active extravasation from the lower pole of the left kidney. Review of angiography demonstrated inadvertent non-fluoroscopic advancement of a Terumo Glidewire into the left renal artery. Superselective coil embolization and polyvinyl alcohol particle infusion achieved hemostasis. The patient’s course was complicated by left ventricular failure and acute kidney injury, necessitating an 8-day hospital stay for recovery. She later underwent a successful transcatheter aortic valve replacement and continues to do well at 2-year follow-up. This case underscores the necessity of wire advancement under fluoroscopic guidance and vigilant post-procedural monitoring.