Surgical Management of Femoral Arterial Sheath Complications (Surgical Repair Tips):

When surgical management of a femoral arterial sheath is required, a cutdown directly over the sheath is recommended to allow controlled removal and minimize hematoma formation. The sheath should be left in place during exposure, as it provides tamponade and serves as a guide to the artery. Bleeding is to be expected when cutting down over a sheath and proximal control should be thought through, whether this is under the inguinal ligament or by gaining control in the retroperitoneum, especially when a hematoma already is present (See Appendix I).

Proximal control may be obtained using endovascular or open techniques. Open technique consists of control of the iliac artery in the abdomen or retroperitoneum. Endovascular methods consist of a REBOA positioned in Zone 3 or Fogarty balloon catheter to provide temporary proximal control. Balloon occlusion at the femoral access site can also be achieved by inserting and inflating a balloon through the existing access prior to cutdown; however, this is an advanced endovascular technique and may not be feasible in austere environments. “Up-and-over” balloon control from the contralateral femoral artery is another option but is often not readily available in deployed settings.

The most reliable proximal control in the setting of a large or expanding hematoma, or when the sheath has already been removed, is open retroperitoneal exposure of the external iliac artery. Surgeons should have a low threshold to proceed directly to retroperitoneal exposure in these scenarios, as proximal control may not be achievable safely from a standard groin approach.

During repair of the access site, arterial dissection and thrombosis are common and should be actively assessed. The arteriotomy should be repaired with attention to full-thickness closure and restoration of luminal integrity. Intraoperative ultrasound is highly useful and may allow assessment of vessel patency, detection of thrombus, and confirmation of distal flow without the need to extend the arteriotomy.