How to deal with a femoral puncture site pseudoaneurysm?  First line is ultrasound-guided compression.  It is straightforward and highly effective.

1. Take a curved abdominal probe
2. Put it over puncture site and turn on color
3. Wiggle probe around until you can see the tract from femoral artery to the pseudoaneurysm
4. Push down on probe until Doppler flow in pseudoaneurysm and tract disappears, while that in femoral artery persists
5. Hold steady for 15-20 min and don’t peek to see if its working.  It hurts the patient a lot.  Consider giving pain meds in advance.  The good news is that your fingers will hurt also.
6. Let go slowly and check to see if tract and pseudoaneurysm flow are gone.
7. If not, consider repeating above 1-2 more times before doing something else.
8. If success, leave patient in bed with leg straight for a while
9. Next time, think radial

Here is a typical ultrasound picture of pseudoaneurysm

Here is a video of how to treat it

Use it in your stubborn femoral access practice, or see list of radial cases here