Femoral Vein

Central
Written By John Hagen

In some institutions or in certain clinical situations (e.g. a patient undergoing a staged repair for a congenital cardiac lesion), femoral access may be the norm. Similar to other anatomic sites, the use of ultrasound increases success rate, reduces the number of needle passes, as well as time to cannulation.

 

Positioning:

Patients are placed supine; abduction of the leg to 60° and external hip rotation may reduce vessel overlap, as well as provide greater exposure and vessel visualization.

Placing the patient in reverse trendelenburg, and compression of the ipsilateral inguinal crease (basically compressing the vessel proximally) may increase the vessel size

Equipment:

  • There is some variability regarding what type of needle one uses to gain access to the vessel

  • Some prefer the “slip-tip” angiocatheter for a couple of reasons:

    • So that they may advance the catheter directly into the vessel prior to a wire exchange

      • This may be particularly useful in situations when having issues threading a wire through a finder needle

    • Others prefer the rigid “finder” needle typically found in most central line kit

      • This offers a more rigid conduit, and is perhaps less likely to be unintentionally pushed out of the vessel during guidewire advancement

  • So far as I can tell, there is no study that compares the efficacy of either strategy, though having flexibility and adapting either technique to a difficult situation seems most prudent

Technique: can be done in short axis out-of-plane or long axis in-plane

Short Axis Out-of-Plane

 

Long Axis In-plane

 

Video: Vessel location with changes in leg position

 

While not as impressive as I had hoped during a scan of my son, one can still see the changes in blood vessel location with each maneuver and can appreciate how they each contribute to realigning the vessels in a more favorable orientation for cannulation.

In vessels that are superimposed in a neutral position (0°), these maneuvers are more than likely much more dramatic.

 
 

Suk et al found that a combination of Reverse Trendelenburg combined with ipsilateral inguinal compression increased cross sectional area of the femoral vein by almost 50%. A follow up study by many of the same researchers found that the optimal place for femoral vein cannulation seems to be at the level of inguinal crease with the leg abducted to 60º and some external hip rotation.

There are no studies comparing short axis vs long axis for femoral vein cannulation. Most (but not all) of the studies in children have looked at ultrasound vs. landmark techniques, which have obviously shown the superiority of using an ultrasound. There are no studies that I am aware of that directly compare a short axis out-of-plane vs long axis in-plane technique in femoral vein cannulation. There is however a study that directly compares the two techniques in femoral arterial cannulation. In this study, Abdelbaser et al found that the long axis technique resulted in a higher first puncture success rate and shorter time to cannulation than the short axis technique—at least in skilled hands. Whether a savings of around 60 seconds is clinically relevant is debatable. Unless were discussing the time it takes to close skin. That is never up for debate!

Aouad, M.T., Kanazi, G.E., Abdallah, F.W., Moukaddem, F.H., Turbay, M.J., Obeid, M.Y. and Siddik-Sayyid, S.M., 2010. Femoral vein cannulation performed by residents: a comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Anesthesia & Analgesia, 111(3), pp.724-728.

Suk, E.H., Kim, D.H., Kil, H.K. and Kweon, T.D., 2009. Effects of reverse Trendelenburg position and inguinal compression on femoral vein cross‐sectional area in infants and young children. Anaesthesia, 64(4), pp.399-402.

Suk, E.H., Lee, K.Y., Kweon, T.D., Jang, Y.H. and Bai, S.J., 2010. Ultrasonographic evaluation of the femoral vein in anaesthetised infants and young children. Anaesthesia, 65(9), pp.895-898.

Pietroboni, P.F., Carvajal, C.M., Zuleta, Y.I., Ortiz, P.L., Lucero, Y.C. and Drago, M., 2020. Landmark versus ultrasound-guided insertion of femoral venous catheters in the pediatric intensive care unit: an efficacy and safety comparison study. Medicina Intensiva (English Edition), 44(2), pp.96-100.

Law, M.A., Borasino, S., McMahon, W.S. and Alten, J.A., 2014. Ultrasound-versus landmark-guided femoral catheterization in the pediatric catheterization laboratory: a randomized-controlled trial. Pediatric cardiology, 35(7), pp.1246-1252.

Aouad, M.T., Kanazi, G.E., Abdallah, F.W., Moukaddem, F.H., Turbay, M.J., Obeid, M.Y. and Siddik-Sayyid, S.M., 2010. Femoral vein cannulation performed by residents: a comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Anesthesia & Analgesia, 111(3), pp.724-728.

Abdelbaser, I., Mageed, N.A., Elmorsy, M.M. and Elfayoumy, S.I., 2022. Ultrasound-guided long-axis versus short-axis femoral artery catheterization in neonates and infants undergoing cardiac surgery: a randomized controlled study. Journal of Cardiothoracic and Vascular Anesthesia, 36(3), pp.677-683.

John Hagen
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