This study examined the relationship between the femoral arteriotomy location and the risk of femoral access site complications after diagnostic and interventional cardiac catheterization procedures. One of the most common complication of cardiac catheterization and percutaneous coronary intervention (PCI) involves the vascular access site. The femoral approach is the most frequent site of vascular access during invasive cardiac procedures. This approach is associated with vascular complications, such as retroperitoneal bleeding, which can be life-threatening. If angiographic predictors of retroperitoneal bleeding can be identified, this complication could be avoided. A prospective cohort of 33 patients with femoral access site complications was subgrouped based on the angiographic arteriotomy site. Concurrent patients without complications were randomly selected to form a control group. Study and control patients were compared on presenting risk factors and outcomes. Logistic regression analysis was used to identify independent predictors for femoral access site complications. Arteriotomy location above the most inferior border of the inferior epigastric artery in patients undergoing PCI was associated with 100% of all retroperitoneal bleeds (P < 0.001). Low, high middle, and high femoral arteriotomy sites were associated with 71% of all vascular access complications. The combination of these locations for the femoral arteriotomy was an independent predictor of adverse vascular access site complications beyond traditional risk factors (odds ratio = 28.7; CI = 6.73-122.40; P < 0.0001). Vascular complications occurred more frequently in patients who were of older age (72 vs. 66 years; P < 0.001). The location of the femoral arteriotomy site assessed by a femoral angiogram is predictive of life-threatening complications. Patients undergoing PCI with an arteriotomy above the most inferior border of the inferior epigastric artery are at an increased risk for retroperitoneal bleeding. This complication may be avoided by risk-stratifying patients prior to intervention with a femoral angiogram. Copyright 2005 Wiley-Liss, Inc