Appendix I: Surgical Management Of Femoral Arterial Sheaths

Indications

- Difficulty with sheath removal
- Large-bore sheath
- Suspected arterial injury (dissection, thrombosis, perforation)
- Expanding or large hematoma (strongly consider retroperitoneal iliac artery control)
- Uncontrolled bleeding
- Coagulopathy
- Prolonged dwell time
- Failed percutaneous removal or inability to achieve hemostasis

Key Principles

- Do NOT remove the sheath blindly if complication is suspected
- Leave the sheath in place to:
  - Maintain access
  - Provide tamponade
  - Guide surgical exposure
- Perform cutdown directly over the sheath for controlled removal and to limit hematoma expansion
- Bleeding should be expected as dissection approaches the artery
- A vascular closure device may be used in select cases, but is not commonly available in deployed environments

Proximal Control (Critical Step)

- Options include:
  - Retroperitoneal control of the iliac artery
  - REBOA in Zone 3
  - Percutaneous proximal endovascular balloon occlusion of iliac artery (advanced technique)
  - Up-and-over balloon from contralateral side over the point of access (advanced technique)
- ⚠️Best option in high-risk scenarios:
  - Retroperitoneal exposure of the external iliac artery
- Strongly consider retroperitoneal exposure when:
  - Large or expanding hematoma
  - Sheath has already been removed and landmarks obscured by hematoma
  - Inadequate control from groin exposure

Surgical Approach (Cutdown Over Sheath)

- Longitudinal incision over access site
- Dissect to expose:
  - Common femoral artery (CFA)
  - Bifurcation (SFA and profunda)
- Carefully expose vessel:
  - Do not dislodge sheath prematurely
  - Control soft tissue bleeding

Obtain Control

- Proximal: CFA ± external iliac
- Distal: SFA and profunda
- Use:
  - Vessel loops (preferred)
  - Clamps if needed

Sheath Removal

- Remove under direct vision after control obtained
- Anticipate:
  - Bleeding as dissection nears point of arteriotomy (arterial entry point)
  - Enlarging arteriotomy to visualize all layers and ensure no dissection or thrombus
  - Thrombus/dissected artery
  - Flushing the arteries and ensuring backbleeding

Assess the Artery

- Evaluate for:
  - Dissection
  - Thrombosis
  - Perforation
- Intraoperative ultrasound (strongly recommended)
  - Confirms patency
  - Identifies thrombus/dissection
  - Assesses distal flow
  - May avoid unnecessary arteriotomy extension

Repair Options

- Primary repair → small defect
- Patch angioplasty (nearby vein best) → larger defect / prevent stenosis
- Interposition graft → segmental injury
- Thrombectomy → if thrombus present (may be required in addition to repair technique above)

Adjuncts

- Heparin (if appropriate)
- Back-bleeding and forward-bleeding prior to closure (flushing the arteries)
- Confirm flow:
  - Palpable pulses
  - Doppler signals
  - Ultrasound
- Closure
- Ensure hemostasis
- Layered closure
- Consider drain if significant bleeding risk

Surgical Management of Femoral Arterial Sheaths Algorithm