What is the proper procedure for removing an arterial femoral sheath?

Proper Procedure for Removing an Arterial Femoral Sheath

The proper procedure for removing an arterial femoral sheath involves careful preparation, monitoring, and compression techniques to achieve hemostasis while minimizing complications such as bleeding, hematoma formation, and pseudoaneurysm development.

Patient Preparation and Assessment

• Before sheath removal, verify that coagulation parameters are appropriate - for patients who received heparin, wait until the activated clotting time (ACT) falls to 150-180 seconds or when the activated partial thromboplastin time falls to 50 seconds 1
• Position the patient supine with the affected leg straight and immobilized 1
• Ensure proper monitoring equipment is in place, including blood pressure monitoring and pulse oximetry 1
• Consider placing an additional pulse oximeter on the foot of the affected leg to provide early warning of femoral artery obstruction or distal thromboembolism 1

Equipment Preparation

• Gather necessary supplies: sterile gloves, antiseptic solution, sterile gauze, compression device (if using), and appropriate dressings
• Ensure emergency equipment is readily available in case of complications
• If using mechanical compression devices (such as FemoStop), prepare according to manufacturer's instructions 2, 3

Sheath Removal Procedure

1. Cleanse the puncture site with antiseptic solution
2. Apply manual pressure 2-3 cm proximal to the puncture site 1
3. While maintaining proximal pressure, smoothly and steadily remove the sheath in a single motion along the angle of insertion 1
4. Immediately apply firm direct pressure to the puncture site for at least 15-20 minutes or until hemostasis is achieved 2, 3
5. Gradually reduce pressure while monitoring for bleeding 1

Hemostasis Methods

• Manual compression remains the traditional approach and has been shown to achieve hemostasis more quickly than mechanical devices in some studies 2
• Mechanical compression devices (e.g., FemoStop) can be used as an alternative to manual compression with comparable safety profiles 2, 3
• For patients on aggressive antiplatelet therapy, both manual compression and vascular closure devices have shown similar safety profiles when used appropriately 4

Post-Procedure Care

• Apply a sterile pressure dressing once hemostasis is achieved 1
• Monitor vital signs and puncture site frequently for the first hour, then periodically for 24 hours 1
• Maintain bed rest with the affected leg straight for 4-6 hours after hemostasis is achieved 3
• Assess distal pulses, color, temperature, and sensation of the affected limb regularly 1
• Monitor for complications including hematoma, pseudoaneurysm, retroperitoneal bleeding, and arteriovenous fistula 1

Special Considerations

• For patients with low body mass index or on antiplatelet therapy, take extra precautions as these are independent risk factors for access site hematoma 5
• Small asymptomatic pseudoaneurysms (<2.0 cm) may resolve spontaneously within 2 months and can be managed conservatively with follow-up ultrasound 1
• Larger pseudoaneurysms (≥2.0 cm) that persist may require surgical intervention 1
• Ultrasound guidance for femoral artery access can reduce complications, particularly in patients with non-palpable pulses 5

Common Pitfalls and How to Avoid Them

• Inadequate compression time leading to rebleeding - ensure sufficient compression duration based on patient's anticoagulation status 2
• Overly vigorous compression causing vessel occlusion - monitor distal pulses during compression 1
• Improper identification of puncture site - use anatomical landmarks or ultrasound guidance to identify the common femoral artery 1, 5
• Failure to recognize complications early - maintain vigilant monitoring of the access site and distal circulation 1
• Premature ambulation - adhere to recommended bed rest duration to prevent rebleeding 3