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INTRODUCTION: Femoral vein (FV) access is a routine procedure performed for emergency need for dialysis. Common complications of FV access include infection, thrombosis, or local hematoma, with a mechanical complication rate as low as 1.5%. Retroperitoneal hematoma is a very rare but fatal complication of FV access. We present a case of rare symptomology of a rare complication of a routine procedure. CASE PRESENTATION: Patient is an 82-year-old male with significant history of coronary artery disease who presented for chronic chest pain that had recently increased in intensity and become associated with lightheadedness. Patient underwent a coronary catheterization which showed chronic total occlusion and no intervention was performed. Patient was started on heparin drip and guideline based therapy. Patient developed acute blood loss anemia for which all anticoagulants were held. Patient's course was complicated with acute renal failure requiring continuous renal replacement therapy (CRRT), for which a left FV access was established under ultrasound guidance. Patient complained of left groin pain, and left leg weakness a few hours after placement of catheter. Hemoglobin at that time was noted to be 9.9 gm/dL. Vital signs were within normal limits. Exam was significant for abscence of local hemtoma, weakness of hip adductors and flexors, decreased sensation over medial thigh, absent left patellar reflex consistent with femoral nerve injury. Symptoms persisted over the next 3 days. Patient's hemoglobin was noted to trend down gradually. On the third day, hemoglobin had dropped to 6.9 gm/dL. A CT scan of the abdomen and pelvis showed an iliopsoas hematoma that was likely causing entrapment/compressive injury of the femoral nerve. There was delay in diagnosis due to patient's unusual presentation. Patient's course was fatally complicated with hypovolemic shock and inability to compensate due to his extensive comorbidities. DISCUSSION: There are only few cases in literature of iliopsoas hematoma as a complication of FV access. This lesion commonly presents as femoral nerve mononeuropathy due to the course that the femoral nerve follows along the iliopsoas muscle. The hematoma causes femoral nerve injury as it gets entrapped due to the enlarging iliopsoas muscle. CONCLUSIONS: Acute kidney injury requiring CRRT is a common management choice in the critical care unit. Establishing femoral venous access has become a routine procedure and rarely results in acute bleeding complications, which are more commonly associated with arterial access. We need to maintain a low threshold for this potentially fatal complication to prevent delay in diagnosis.

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