If arterial pressure monitoring is still required, perform at an alternate arterial line site. Prior to removal, an angiogram through the sheath to document distal limb perfusion is best practice, though not always available. If a large sheath size is used, a patient is coagulopathic, or there is technical difficulty in sheath removal, a cut down and arterial repair, patch or graft may be required. This may be best accomplished in the Role 3 environment with access to specialists and/or surgical backup.26 It is also helpful to leave the sheath in place when performing a surgical repair as this will help guide to the location of the access during the exposure of the femoral artery.

When there is concern for re-bleeding, the sheath may be left in place without aortic occlusion. By leaving the sheath in place, the REBOA can easily be reinserted, and aortic occlusion can quickly be obtained if rebleeding occurs or hemorrhage continues.60,76 In general, and situation/resource dependent, the sheath should be left in place during any active or ongoing resuscitation. The sheath should not be removed immediately prior to transport and is best removed where vascular complications can be treated and managed. See section on indwelling sheath management.