Appendix H: Suspected Thrombosed Arterial Sheath

Recognition

- Difficulty or inability to aspirate blood
- Resistance to flushing
- Dampened or absent arterial waveform
- Clinical concern for limb ischemia

Assume thrombosis until proven otherwise

CRITICAL WARNING

- DO NOT FLUSH A THROMBOSED SHEATH
  - Risk: distal embolization
  - Consequence: acute limb ischemia, limb loss

Immediate Actions

- Stop all attempts to flush
- Maintain sterile technique and cleanse sheath
- Prepare for sheath exchange with equal or greater sized sheath

Sheath Exchange (Preferred Management)

- Insert guidewire through existing sheath
- Confirm intraluminal position (fluoro if available)
- Remove thrombosed sheath over the wire
- Apply manual pressure during removal
- Advance new sheath over wire: Same size or slightly larger
- Flush and secure new sheath
- Resume continuous flow or place on pressure

Adjuncts

- If fluoroscopy available:
  - Use for wire confirmation and exchange
- Consider angiography after exchange:
  - Assess distal flow
  - Evaluate for embolization

Post-Exchange Care

- Ensure sheath flushed of all visible blood
- Resume pressure or continuous flow immediately
- Repeat neurovascular checks (hourly minimum)
- Monitor closely for:
  - Limb ischemia
  - Re-thrombosis
  - Access complications

Suspected Thrombosed Arterial Sheath Algorithm