Venous access can be obtained through the cannulation of peripheral (e.g., antecubital vein, saphenous vein) or central veins (e.g., internal jugular vein, femoral vein). The insertion of a central venous line is potentially life-saving as, in emergent situations, it allows rapid administration of high-volume isotonic fluids and medications that would otherwise be caustic to peripheral veins. This article will focus on central venous access via the femoral vein. However, there are some aspects applicable to other central venous access sites.
In the leg, venous drainage flows proximally from the popliteal vein to the superficial femoral vein. Continuing proximally, the superficial femoral vein is joined by the deep femoral vein in the upper thigh becoming the common femoral vein. The great saphenous vein then joins the common femoral vein near the inguinal ligament. Superior to the inguinal ligament, the common femoral vein becomes the external iliac vein. The internal iliac vein drains into the external iliac vein becoming the common iliac vein, and the common iliac veins join to become the inferior vena cava (IVC).
The common femoral vein is the ideal vein to puncture when performing central venous access at the femoral site. The common femoral vein lies within the “femoral triangle” in the inguinal-femoral region. This region is bordered by the inguinal ligament superiorly, the adductor longus medially, and the sartorius muscle laterally. It is important to understand the relationship of structures within the inguinal-femoral region which can be remembered by using the mnemonic “NAVEL.” Moving laterally to medially, (N) femoral nerve, (A) femoral artery, (V) femoral vein, (E) empty space, (L) lymphatics. FOr the remainder of this article the term femoral vein to refer to the common femoral vein unless otherwise specified.
When obtaining the central venous access in the femoral vein, the key anatomical landmarks to identify in the inguinal-femoral region are the inguinal ligament and the femoral artery pulsation. In most instances, central venous access with ultrasound-guidance is considered the standard of care. Nevertheless, the understanding and use of anatomical landmarks are equally important and when used in combination with ultrasound guidance, lead to increased success.
In general, the indications for central venous access include the following:
Note that the indications mentioned above are not absolute. The balance of risks and benefits when performing the procedure should be considered for each patient. The indication for line placement also prompts the proceduralist to consider additional factors.
Is short-term or long-term access (e.g., peripherally inserted central catheter (PICC)) or implantable venous access (Port-a-cath or Broviac catheter) more beneficial to the patient?
Potential contraindications to central venous access via the femoral vein are the following:
Since this procedure has life-saving potential, the contraindications noted above are relative. Additionally, if these issues are encountered at the femoral site, an alternative site (e.g., internal jugular vein, subclavian vein) should be considered.
The following is standard equipment needed to perform central venous access; although, institutional variability may exist. Additionally, some vendors have pre-assembled kits that may contain a number of these items.
A sterilized individual to assist with opening packaging and handing sterile equipment in a manner that maintains the sterile field is generally helpful. Additionally, a separate individual to provide sedation/analgesia and monitor effects is ideal and safest for the patient. Lastly, a second, sterilized individual may be required to assist with ultrasonography depending on the comfort and/or experience of the proceduralist.
Employ the “landmark technique” to isolate the location of the femoral vein for puncture. There are several methods to do this, and some examples are to:
At the desired location and using the slip tip syringe-introducer needle complex, puncture the skin at a 30 to 45-degree angle to the skin.
Complications from central venous access can be classified into early and late complications. Again, some of these are not specific to the femoral site and can occur with insertion at other central venous access sites.
The following are not complications, per se, but can lead to complications:
CLABSIs are the most common complication of central venous catheter placement. CLABSIs are a source of significant morbidity and mortality, as well as, increased healthcare cost. A majority of the equipment, preparation, and technique described above have been incorporated into bundled practices and checklists that have been shown to reduce the incidence of CLABSIs. In adults, the femoral site is avoided due to evidence demonstrating a higher risk of bloodstream infection relative to other sites. However, this has not been demonstrated in children, and the femoral site is a preferred site in this population due to ease of access. Lastly, long-term central venous access, such as PICCs, have also been associated with a relatively lower risk of bloodstream infections.