After completion of the procedure and deflation of the balloon, both the REBOA balloon catheter (and wire if used) may be removed and various techniques may be employed to remove the device, ensuring there is no clot in the sheath or distal extremity of the sheath. The sheath can then be removed through a surgical longitudinal incision through the groin, exposing both distal and proximal areas to the sheath, before adequate closure of the artery [
8]. In a 5-year retrospective study of 48 patients that underwent REBOA, the development of distal thrombus and arterial dissection was a common occurrence, due to the extended periods of occlusion after insertion of the sheath. Five patients required additional vascular procedures; two required thrombectomy with repair of the dissection flap and patch angioplasty; one required thrombectomy with patch angioplasty; one required thrombectomy, interposition graft, and prophylactic fasciotomy; and one required thrombectomy with repair of dissection flaps. None of these patients experienced any complications from the procedures [
16]. Lower limb ischemia resulting in amputation has also been a reported complication following sheath removal. In a 6-year retrospective study conducted in Tokyo, Japan (
n = 24), two patients experienced lower limb ischemia following sheath removal, both of which required amputation below the knee. This is resultant from the prolonged systemic ischemia [
24]. The study also reported other major systemic complications, including nine patients who experienced acute kidney injury and nine patients with multi-organ failure; also complications of systemic ischemia [
24]. The inflammatory sequelae of REBOA is not well understood, but these results mandate the need for aggressive and pre-emptive diagnosis and treatment of ischemic metabolites, clinical consequences of prolonged aortic occlusion, and unrecognized procedural vascular complications. Vigilant assessment of abdominal end organ and distal extremity perfusion is critical, and imaging access sites within 24–48 h of sheath removal is prudent.