Background: The Heimlich maneuver has become the technique of choice for choking victims. While effective, complications are often overlooked. We present a unique case of splenic pseudoaneurysm formation and delayed rupture due to the Heimlich maneuver. Case: 86-year-old male with medical history of diabetes mellitus, hypertension, lung cancer, chronic obstructive pulmonary disease, end stage renal disease on hemodialysis, was found to be choking on food. The Heimlich maneuver was performed, and food particles were expelled. He was briefly intubated and hospitalized. On day 2 of admission, patient developed a sudden drop in hemoglobin from 11 g/dL to 7.4 g/dL on routine labs, subsequently down to a low of 5.6 g/dL. Vital signs were stable. Physical exam was significant for mild diffuse tenderness and distension without peritoneal signs. An abdominal CT scan without contrast revealed hemoperitoneum collecting in a right inguinal hernia and no free air. A CT angiogram of the abdomen and pelvis was then performed, revealing a subcapsular/perisplenic hematoma and adjacent splenic pseudoaneurysm in the anterior upper pole of the spleen (Figure). Selective arteriogram of the celia-comesenteric trunk confirmed a splenic pseudoaneurysm, which was successfully embolized using multiple embolization coils. The patient's hemoglobin stabilized after the embolization and transfusion of 4 units of packed red blood cells. He was started on a dysphagia diet with thickened liquids for pharyngeal dysphagia. Discussion: This is the first reported case of a splenic pseudoaneurysm secondary to the Heimlich maneuver to our knowledge in the English literature. Complications of the Heimlich maneuver including bowel and splenic rupture, aortic thrombosis and solid organ lacerations have been reported. The elderly are especially susceptible to these adverse events due to comorbidities, as well as an increased incidence of dysphagia. This case highlights a delayed complication of the Heimlich maneuver. A high index of suspicion is warranted, and all choking victims on whom the maneuver has been performed should undergo medical examination.Figure: [859] A perisplenic hematoma is seen (arrow). Adjacent high attenuation density following blood pool was consistent with a pseudoaneurysm.