Real-World Outcomes of Immediate Femoral Sheath Removal After Emergency Embolization in the Age of Ultrasound-Guided Device-Assisted Vascular Closure

<b>Background/Objectives</b>: Emergency arterial embolization is a life-saving procedure typically performed via femoral access. This study evaluated the safety and efficacy of immediate femoral sheath removal following emergency embolization. <b>Methods</b>: A retrospective cohort study was conducted at a Level 1 trauma center (January 2022-May 2025). Adult patients undergoing emergency embolization with immediate sheath removal were included. Endpoints were reintervention (repeat embolization within 7 days) and access site complications. Multivariate logistic regression identified independent predictors of outcomes. <b>Results</b>: A total of 322 emergency embolization procedures in 299 patients were included. The most common indication was gastrointestinal hemorrhage (45.7%). Vascular closure devices (VCDs) were used in 92.5% of cases. The re-intervention rate was 4.0% (13/322). The overall access site complication rate was 6.2% (20/322), with a major complication rate of 0.9% (3/322). On univariate analysis, pre-procedural platelet level ≤ 80 × 10⁹/L (<i>p</i> = 0.034) and INR > 1.5 (<i>p</i> = 0.034) were significantly associated with an increased risk of complications. On multivariate analysis, pre-procedural platelets ≤ 80 × 10⁹/L was the strongest independent predictor of access site complications (OR 7.28, 95% CI 1.51-35.12; <i>p</i> = 0.013). Choice of vascular closure device was an independent predictor for both reintervention and complications (<i>p</i> < 0.05), likely reflecting bias. <b>Conclusions</b>: Immediate femoral sheath removal following emergency embolization is safe for most patients. However, thrombocytopenia is a significant risk factor for access site complications. A risk-stratified approach with consideration for delayed sheath removal is warranted for patients with platelet counts ≤ 80 × 10⁹/L.