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