Management of Femoral Artery Thrombosis After REBOA
Femoral artery thrombosis after REBOA requires immediate vascular surgical consultation for thrombectomy or endovascular intervention, as this complication is associated with limb ischemia and potential amputation if not promptly addressed.
Immediate Recognition and Assessment
Femoral artery thrombosis is a recognized vascular access site complication (VASC) following REBOA, occurring in approximately 7% of cases 1. The condition manifests as:
- Acute limb ischemia signs: absent pulses, pallor, pain, paresthesias, and paralysis in the affected extremity 1
- Doppler ultrasound confirmation: should be performed immediately to document arterial occlusion 2, 1
- Associated findings: hematoma (40% of VASC cases) and pseudoaneurysm (26%) may coexist 1
The risk is particularly elevated when ultrasound guidance was not used for initial femoral access 2, 1.
Definitive Management Algorithm
First-Line Intervention: Surgical Thrombectomy
Surgical thrombectomy should be the primary intervention for femoral artery thrombosis after REBOA, particularly when medical management fails within 24 hours 3. The procedure involves:
- Direct arteriotomy of the common femoral artery 3
- Fogarty catheter embolectomy (3.0-4.0 F) to remove thrombus from proximal and distal segments 3
- Restoration of antegrade and retrograde flow 3
- Patch angioplasty for arterial closure if needed (used in 21% of VASC cases) 1
This approach is supported by evidence showing rapid resolution of ischemic symptoms post-thrombectomy 3.
Alternative: Endovascular Intervention
When surgical expertise is limited or patient factors favor less invasive approaches:
- Catheter-directed thrombolysis may be considered 2
- Mechanical thrombectomy via interventional radiology 2
However, these should not delay definitive treatment if limb viability is threatened.
Adjunctive Medical Management
Anticoagulation Protocol
- Immediate systemic heparinization: Start unfractionated heparin infusion upon diagnosis 2, 3
- Thrombolytic therapy (t-PA): Consider if no response to heparin within 24 hours, though surgical intervention should not be delayed beyond this timeframe 3
- Post-procedure anticoagulation: Continue heparin or transition to other anticoagulants to prevent re-thrombosis 3
Critical caveat: The absence of heparin use during aortic occlusion has been identified as a contributing factor to thrombosis development 2. However, in the acute trauma setting, systemic anticoagulation during REBOA is often contraindicated due to ongoing hemorrhage.
Outcomes and Complications
- Limb ischemia: Occurs in 15% of VASC cases versus 4% without VASC 1
- Arterial bypass procedures: Required in 3% of VASC cases 1
- Amputation risk: Uncommon (3% in VASC cases versus 0.4% without) but increases with delayed intervention 1
- Resolution: Rapid improvement in clinical signs typically occurs after successful thrombectomy 3
Prevention Strategies for Future Cases
While not directly addressing current thrombosis management, understanding prevention is crucial:
- Ultrasound-guided femoral access: Reduces VASC rate from 9.2% to 5% and is protective against complications 1
- Appropriate sheath sizing: Though sheaths >7 Fr were not independently associated with increased VASC in one study 1, minimizing catheter size when possible is prudent
- Early vascular surgery involvement: Given that vascular injuries can occur during REBOA insertion, particularly in elderly patients with calcific vessels 4
Key Clinical Pitfalls
- Delayed recognition: Continuous monitoring of distal pulses and perfusion is essential during and after REBOA 1
- Relying solely on medical management: Heparin and thrombolytics alone often fail; surgical consultation should occur immediately, not after 24-48 hours of failed medical therapy 3
- Inadequate post-procedure surveillance: VASC can develop hours after REBOA removal 1
- Failure to obtain vascular surgery backup: REBOA should only be performed where experienced vascular surgical support is available for managing complications 4