Femoral Femoral LineLine

Malik AL-RawahiMalik AL-Rawahi

ObjectivesObjectives

Introduction. Anatomy. Advantages and Disadvantage. Indications and Contraindications. Video.

IntroductionIntroduction

All routes of central venous access are associated with complications and possible failure.

The less than ideal conditions under which such access is established also contribute to the incidence of complications.

One of the most common methods to gain central venous access in emergent situations is via femoral vein cannulation.

The technique of accurately placing a femoral vein catheter depends on appropriate patient selection and a sound knowledge of anatomy.

As with most other central venous cannulations, the modified Seldinger technique is used.

AnatomyAnatomy

The femoral vein lies within the femoral triangle in the inguinal-femoral area.

The superior border of the triangle is formed by the inguinal ligament.

The medial border by the adductor longus. The lateral border by the sartorius muscle. The apex of the triangle is formed by the sartorius crossing the

adductor longus muscle. The roof of the triangle is composed of the skin, subcutaneous

tissue, the cribriform fascia, and the fascia lata. The concave floor is formed of underlying adductor longus,

adductor brevis, pectineus, and iliopsoas muscles.

The neurovascular bundle consists of the femoral vein, artery, and nerve, and lies within the triangle in a medial-to-lateral position.

The femoral sheath encloses the femoral artery and vein, and the nerve lies outside the sheath.

The femoral canal is a space within the femoral sheath and medial to the femoral vein.

The femoral artery lies at the mid-inguinal point, which lies midway between pubic symphysis and the anterior superior iliac spine.

The surface anatomy of the femoral vein is identified for venipuncture by palpating the point of maximal pulsation of the femoral artery immediately below the level of the inguinal ligament and marking a point approximately 0.5 cm medial to this pulsation.

Distally in the leg, the femoral vein lies almost posterior to the artery. This is important because arterial puncture is more likely in the sites distal to the inguinal ligament.

AdvantagesAdvantages

In patients who are critically ill because the femoral area is relatively free of other monitoring and airway access devices.

In patients with severe coagulopathy or profound respiratory failure, femoral access precludes the risks of a development of a hemothorax or pneumothorax, both of which are potential complications of supraclavicular venous access.

COMPLICATIONSCOMPLICATIONS Infection Bleeding Thrombosis Intra-abdominal organ injury Nerve injury

IndicationsIndications

Emergency venous access during CPR. In hypotensive trauma patients, with failure of peripheral

lines. It is preferred to supraclavicular central venous access in

patients with suspected superior vena caval injuries. Urgent or emergent hemodialysis access. Hemoperfusion access in patients with severe drug

overdose. Central venous pressure monitoring.

Absolute Absolute ContraindicationsContraindications

Venous injury at the level of the femoral veins or proximally.

Known or suspected thrombosis of the femoral or iliac veins on the proposed side of venous cannulation.

Ambulatory patient (Ambulation increases the risk of catheter fracture and migration)

Relative Relative ContraindicationsContraindications

Presence of bleeding disorders. Distortion of anatomy due to local injury or deformity. Previous long-term venous catheterization. Absence of a clearly palpable femoral artery. History of vasculitis. Prior injection of sclerosis agents. Previous radiation therapy.

EQUIPMENTEQUIPMENT

Clear fenestrated plastic drape Paper drape Chlorhexidine antiseptic with applicators 1% lidocaine Small anesthetizing needle (25 gauge × 1 inch) Large anesthetizing/finder needle (22 gauge × 1.5 inch) Introducer needle (18 gauge × 2.5 inch) Several syringes, 5 mL each J-tipped guidewire with housing and a straightener sleeve Scalpel with a No. 11 blade Skin dilator Catheter (e.g., triple lumen or sheath introducer) Gauze pads Suture with curved needle

Triple-lumen catheter kit.

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