Placement of femoral venous catheters
- Mark P Androes, MD
Mark P Androes, MD
- Assistant Professor of Surgery
- University of South Carolina School of Medicine
- Alan C Heffner, MD
Alan C Heffner, MD
- Director of Critical Care
- Director of ECMO Services
- Pulmonary and Critical Care Consultants
- Department of Internal Medicine
- Department of Emergency Medicine
- Carolinas Medical Center
- Associate Clinical Professor
- University of North Carolina School of Medicine
- Section Editors
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [1-4]. Although femoral vein cannulation is often considered less desirable due to higher complication rates, the femoral veins remain a reliable central venous access site, particularly under urgent or emergent circumstances [5,6]. The femoral site is increasingly used for the introduction of venous devices (eg, inferior vena cava, iliac venous stent).
Femoral venous cannulation and catheter placement will be reviewed here. General considerations for venous access and issues related to other access sites are discussed elsewhere. (See "Overview of central venous access" and "Complications of central venous catheters and their prevention" and "Placement of jugular venous catheters" and "Placement of subclavian venous catheters".)
The femoral veins are commonly viewed as an alternative access site for central venous access due to higher incidence of infection and catheter-related deep vein thrombosis compared with jugular or subclavian access (table 1). With contemporary skin preparation and proper routine catheter maintenance, infection rates appear to be comparable to other sites [7-9]. A meta-analysis suggests there is no longer a demonstrable difference in infection risk based upon catheter position . However, short-term use does not completely eliminate the risk of deep vein thrombosis, which can occur within one day of cannulation [11,12]. (See 'Complications' below.)
The femoral veins are frequently preferred when other access sites are exhausted or there is increased risk for complications such as with emergency access, coagulopathy, and in the uncooperative patient . The femoral veins are generally easier to cannulate and provide dependable access for less-experienced operators, or when there is concern for arterial injury at upper extremity sites because of altered local anatomy. Caution is needed when this approach is used in pulseless patients because chest compressions can produce femoral venous pulsations that may be misinterpreted as arterial. Catheter misplacement at the femoral site occurs in up to 30 percent of cardiac arrest resuscitations [14,15].
Femoral venous access is also used for the delivery of most inferior vena cava filters, and for lower extremity venous intervention. (See "Placement of vena cava filters and their complications".)
- Beddy P, Geoghegan T, Ramesh N, et al. Valsalva and gravitational variability of the internal jugular vein and common femoral vein: ultrasound assessment. Eur J Radiol 2006; 58:307.
- Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access--a systematic review. Crit Care Med 2002; 30:454.
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123.
- DUFFY BJ Jr. The clinical use of polyethylene tubing for intravenous therapy; a report on 72 cases. Ann Surg 1949; 130:929.
- Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001; 286:700.
- Trottier SJ, Veremakis C, O'Brien J, Auer AI. Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial. Crit Care Med 1995; 23:52.
- Parienti JJ, Thirion M, Mégarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 2008; 299:2413.
- Hamilton HC, Foxcroft DR. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Syst Rev 2007; :CD004084.
- Deshpande KS, Hatem C, Ulrich HL, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med 2005; 33:13.
- Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 2012; 40:2479.
- Botha R, van Schoor AN, Boon JM, et al. Anatomical considerations of the anterior approach for central venous catheter placement. Clin Anat 2006; 19:101.
- Meredith JW, Young JS, O'Neil EA, et al. Femoral catheters and deep venous thrombosis: a prospective evaluation with venous duplex sonography. J Trauma 1993; 35:187.
- Kuhn GJ, White BC, Swetnam RE, et al. Peripheral vs central circulation times during CPR: a pilot study. Ann Emerg Med 1981; 10:417.
- Emerman CL, Bellon EM, Lukens TW, et al. A prospective study of femoral versus subclavian vein catheterization during cardiac arrest. Ann Emerg Med 1990; 19:26.
- Jastremski MS, Matthias HD, Randell PA. Femoral venous catheterization during cardiopulmonary resuscitation: a critical appraisal. J Emerg Med 1984; 1:387.
- SELDINGER SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953; 39:368.
- Tanner J, Moncaster K, Woodings D. Preoperative hair removal: a systematic review. J Perioper Pract 2007; 17:118.
- Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet 2015; 386:2069.
- Ely EW, Hite RD, Baker AM, et al. Venous air embolism from central venous catheterization: a need for increased physician awareness. Crit Care Med 1999; 27:2113.
- Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007; 106:164.
- Bannon MP, Heller SF, Rivera M. Anatomic considerations for central venous cannulation. Risk Manag Healthc Policy 2011; 4:27.
- Stone MB, Price DD, Anderson BS. Ultrasonographic investigation of the effect of reverse Trendelenburg on the cross-sectional area of the femoral vein. J Emerg Med 2006; 30:211.
- Brass P, Hellmich M, Kolodziej L, et al. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 2015; 1:CD011447.
- Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg 2008; 48:918.
- Sznajder JI, Zveibil FR, Bitterman H, et al. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986; 146:259.
- Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002; 28:1.
- Boyd R, Saxe A, Phillips E. Effect of patient position upon success in placing central venous catheters. Am J Surg 1996; 172:380.
- Fronek A, Criqui MH, Denenberg J, Langer RD. Common femoral vein dimensions and hemodynamics including Valsalva response as a function of sex, age, and ethnicity in a population study. J Vasc Surg 2001; 33:1050.
- Albuquerque Júnior FC, Vasconcelos PR. Technical aspects of central venous catheterization. Curr Opin Clin Nutr Metab Care 1998; 1:297.
- Ezaru CS, Mangione MP, Oravitz TM, et al. Eliminating arterial injury during central venous catheterization using manometry. Anesth Analg 2009; 109:130.
- Horowitz R, Gossett JG, Bailitz J, et al. The FLUSH study--flush the line and ultrasound the heart: ultrasonographic confirmation of central femoral venous line placement. Ann Emerg Med 2014; 63:678.
- Propp DA, Cline D, Hennenfent BR. Catheter embolism. J Emerg Med 1988; 6:17.
- Robinson JF, Robinson WA, Cohn A, et al. Perforation of the great vessels during central venous line placement. Arch Intern Med 1995; 155:1225.
- Chalkiadis GA, Goucke CR. Depth of central venous catheter insertion in adults: an audit and assessment of a technique to improve tip position. Anaesth Intensive Care 1998; 26:61.
- Gaballah M, Krishnamurthy G, Keller MS, et al. US-guided placement and tip position confirmation for lower-extremity central venous access in neonates and infants with comparison versus conventional insertion. J Vasc Interv Radiol 2014; 25:548.
- FEMORAL VEIN ANATOMY
- GENERAL PREPARATION
- Skin preparation
- FEMORAL VEIN CANNULATION
- Dynamic ultrasound-guided femoral access
- Needle placement
- - Access with introducer needle
- - Using finder needle
- - Using an angiocatheter
- Venous confirmation
- CATHETER PLACEMENT
- Guidewire handling
- Tract dilation
- Positioning the catheter
- Catheter flushing and fixation
- CONFIRMATION OF FEMORAL CATHETER POSITION
- CATHETER MANAGEMENT
- SUMMARY AND RECOMMENDATIONS