# Situation: A nurse on the pediatric cardiology and surgical ward cares for infants with congenital anomalies. A 10-month-old had cardiac catheterization through the right femoral artery for device closure of a ventricular septal defect 4 hours ago. The nurse finds: Heart rate: 132/min; blood pressure: 90/56 mmHg Insertion site: dressing dry, no swelling Right foot: cool and pale, weak pedal pulse, capillary refill 4 seconds Left foot: warm and pink, strong pedal pulse What is the MOST likely problem?

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## 문제

Situation: A nurse on the pediatric cardiology and surgical ward cares for infants with congenital anomalies.

A 10-month-old had cardiac catheterization through the right femoral artery for device closure of a ventricular septal defect 4 hours ago. The nurse finds:
Heart rate: 132/min; blood pressure: 90/56 mmHg
Insertion site: dressing dry, no swelling
Right foot: cool and pale, weak pedal pulse, capillary refill 4 seconds
Left foot: warm and pink, strong pedal pulse
What is the MOST likely problem?

## 보기

1. Reduced arterial blood flow to the right leg **✔ 정답**
2. Hidden bleeding leading to hypovolemic shock
3. Hypothermia from the cold procedure room
4. Expected vasoconstriction that needs no action

**정답: 1**

## 해설

Changes limited to the catheterized limb — coolness, pallor, a weak pulse, and slow capillary refill — while the other foot is normal point to arterial obstruction, such as thrombosis or spasm, at the insertion site. Heart rate and blood pressure are normal for the age and the site is dry, so the problem is local; the nurse reports it at once.

## 심화 해설

Clinical situation The findings are confined to the right lower extremity: the foot is cool and pale, the pedal pulse is weak, and capillary refill is prolonged at 4 seconds. The left foot remains warm and pink with a strong pulse. This asymmetry is the key clue. A systemic problem such as hypovolemic shock or hypothermia would affect both legs, not one. The dressing is dry and there is no swelling at the insertion site, so visible bleeding is not the immediate concern. The heart rate of 132/min and blood pressure of 90/56 mmHg are within acceptable limits for a 10-month-old infant, which further argues against a systemic perfusion problem. The unilateral cool, pale extremity with weak pulse and delayed capillary refill indicates reduced arterial inflow to the right leg, most likely from thrombus or spasm at the femoral artery access site.

Why the right leg loses arterial flow after catheterization During transfemoral cardiac catheterization, the catheter passes through the femoral artery. The vessel wall can be injured by the puncture, the catheter, or the closure device. This injury triggers platelet activation and local thrombus formation, or it can provoke arterial spasm. Either mechanism narrows or occludes the vessel lumen. The result is acute limb ischemia—a sudden drop in arterial perfusion distal to the obstruction. In infants, the femoral artery is small in diameter, so even a modest thrombus can significantly reduce flow. The classic findings of acute arterial occlusion are the “six Ps,” but in an infant the most observable signs are coolness, pallor, weak or absent pulse, and delayed capillary refill. Pain and paresthesia are harder to assess in a 10-month-old, so the nurse relies on objective perfusion signs.

How the evidence supports a local arterial problem The case report by El Hanbali and colleagues describes a 13-month-old child who developed acute ischemia of the right lower limb after inadvertent femoral arterial injury during a vascular access procedure [1]. The presentation mirrors this scenario: a unilateral cool, pale limb with poor perfusion following femoral artery instrumentation. The mechanism is iatrogenic arterial trauma leading to thrombosis. Flanigan and colleagues prospectively studied children before and after cardiac catheterization and found that 24% sustained vascular injuries, with transfemoral cardiac catheterization being a major cause . This underscores that arterial complications after femoral access are not rare in pediatric patients and must be actively assessed. Katsouras and colleagues reported acute lower limb ischemia after use of a vascular closure device, with an incidence of 0.7% in their series . Although the incidence is lower with modern devices, the complication is serious and requires prompt recognition.

| Assessment finding | Supports local arterial obstruction | Does not support systemic problem |
| --- | --- | --- |
| Right foot cool and pale | Yes—reduced arterial inflow to that limb | No—systemic hypoperfusion would affect both feet |
| Weak right pedal pulse | Yes—diminished flow distal to femoral obstruction | No—left pedal pulse is strong |
| Capillary refill 4 seconds | Yes—delayed distal perfusion in the affected limb | No—left foot refill is normal |
| Heart rate 132/min, BP 90/56 mmHg | Neutral—not the primary indicator | Yes—age-appropriate, argues against shock |
| Dressing dry, no swelling | Neutral—does not rule out arterial thrombus | Yes—no visible bleeding or expanding hematoma |

Distinguishing arterial obstruction from other options Watch out! Hypovolemic shock from hidden bleeding would present with tachycardia, hypotension, prolonged capillary refill in all extremities, and often a change in mental status. This infant has a normal heart rate and blood pressure for age, and the left foot is well perfused. Watch out! Hypothermia would also cause symmetric coolness and vasoconstriction in both feet, not a one-sided change. Key point! Unilateral limb changes after femoral artery catheterization are never “expected” and always require immediate reporting. Vasoconstriction limited to one catheterized limb is a sign of arterial compromise until proven otherwise.

Nursing priority The nurse should immediately notify the provider and the pediatric cardiology team. While waiting for further orders, the nurse keeps the infant calm, maintains the leg in a neutral position, avoids flexion at the hip that could kink the femoral artery, and continues to monitor perfusion of the right foot. The unaffected left foot serves as the child’s own control. Serial assessment of color, temperature, pulse, and capillary refill in the affected limb is essential because progression from weak pulse to absent pulse signals worsening ischemia and the need for urgent intervention.References (research sources)

- [1]Acute Limb Ischemia in an Infant Following Inadvertent Femoral Arterial Injury During Central Venous Access.Research articleEl Hanbali A, Ziani H, Drouzi L, Talbi H, Hamdani Z, Byadi M, Ennafiri M, Nabil N, Ed-Dafali L, El Harrak S, Bentalha A, Koraichi A, El Kettani SEE. (2026) · DOI: 10.1002/ccr3.73073

## 임상 시나리오

Post-Catheterization Limb AssessmentDetecting femoral artery occlusion in infants
After transfemoral cardiac catheterization, assess the affected limb for asymmetric perfusion: compare color, temperature, pulse strength, and capillary refill between both feet. A unilateral cool, pale foot with weak pulse and capillary refill 4 seconds suggests acute arterial occlusion from thrombus or spasm at the access site.

Normal heart rate 132/min and blood pressure 90/56 mmHg in a 10-month-old, with a dry dressing and no swelling, point to a local vascular problem, not hypovolemic shock or hypothermia. Systemic issues would affect both legs symmetrically.

CautionReport unilateral limb ischemia immediately to the provider. Do not wait or dismiss it as expected vasoconstriction—infants have small femoral arteries, and even a small thrombus can critically reduce flow.

## 핵심 개념

- **Acute limb ischemia** — Sudden reduction in arterial perfusion to an extremity, causing coolness, pallor, weak pulse, and delayed capillary refill
- **Femoral artery catheterization** — Access through the femoral artery for cardiac procedures; carries risk of thrombosis or spasm at the puncture site
- **Capillary refill time** — Normal is under 2 seconds; 4 seconds indicates impaired peripheral perfusion
- **Ventricular septal defect** — A congenital opening between the ventricles allowing left-to-right shunt; may be closed via catheter device
- **Neurovascular assessment** — Evaluation of pulses, color, temperature, sensation, and movement of an affected limb after vascular procedures

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