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