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Femoral vein cannulation: A review
TheJournai of EmergencyMedicme.Vol 2. pp 367-372. 1985 Printed In the USA ??CopyrIght c 1985 Pergamon PressLtd
FEMORAL VEIN CANNULATION:
A REVIEW
Robert H. Dailey, MD Cllnlcal Professor, Unlverslty of Callfornla at San Francisco. and Chief. Emergency MedIcme. Hlghland General Hospital, Oakland, Callfornla Reprint address. Robert H. Dailey, MD, Chief, Emergency Medune. Highland General Hospital, 1411 East 31 st Street. Oakland, CA 94602
Cl Abstract -The femoral vein is an excellent potential venous access site. The technique of cannulation is described and its applications and complications are reviewed. More extensive future use of this technique is necessary to determine its proper role in emergency medicine.
the last 10 years, however, the successful use of the femoral vein for a variety of purposes (principally hemodialysis), warrants a reexamination of the experience in cannulation of this vein.
3 Keywords-femoral
Anatomy
vein; intravenous
lines
Introduction
Venous access in the hypovolemic ill or injured patient continues to challenge the emergency physician’s skills. Traditional access has used catheter-over-needle devices in the superficial veins of the arms, and cutdowns on those same veins or the superficial saphenous vein at the ankle. In the past 20 years, considerable attention has been given to percutaneous catheterization of tne subclavian and internal jugular veins. In the last two to three years, the increasing use of J-wire-guided catheters has allowed use of the external jugular vein. However, the use of the femoral vein has remained relatively neglected, and not without reasons: earlier reports in adults described impressive complications.‘-3 In
Z=ZZXE -
The femoral vein is quite large (12 to 16 mm in diameter).“ Its anatomy is relatively predictable (Figure 1): it arises deep in the thigh, becomes relatively superficial as it crosses the inguinal ligament, then dives deep into the pelvis as the external iliac vein. Below the inguinal ligament, it lies consistently just medial to the femoral artery. However, above the inguinal ligament, it crosses beneath the femoral artery, joining the inferior vena cava to the right of the aorta. The femoral arterial pulse is an extremely useful landmark for locating the vein in the patient with demonstrable pulse. However, in the pulseless patient, cannulation is truly “blind”; therefore, the location of the femoral vein must be related to contiguous bony prominences. Here some confusion exists about the anatomy. Using the
Techniques and Procedures features practical, “how-to” articles of interest to all practicing emergency physicians. This section is coordinated by George Sternbach, MD Stanford University Medical Center.
RECEIVED: 1 June
1984; ACCEPTED: 25 October 367
1984
0736-4679185
$3.00
+ .OO
Robert H.
Dailey
Figure 1. Femoral vein anatomy.
anterior superior iliac spine and the pubic tubercle as external landmarks, different authors describe the location of the artery as (a) at the midpoint of the junction of the medial and middle thirds of a straight line drawn between these two landmarks”; or (6) at the midpoint between those landmarks.6 This confusion may be explained somewhat by the fact that the operator does not enter the femoral vein in a line drawn directly between those two points, but rather inferior to it (Figure 2); nor has anyone actually performed dissections to define these anatomical relationships. In our experience, the femoral artery is found at the inguinal ligament just inferior to the point described in (a) above.
Equipment
Previously, a very large-bore (14-gauge) and long-beveled needle were necessary for catheter-through-needle cannulation; but this unit required that the entire needle bevel be
in the vein for successful catheter-threading. When improperly directed, this large needle could cause serious arterial and pleural punctures. These disadvantages have been lessened by wire-guided (Seldinger) catheter techniques. The “step-up” capability of the Seldinger technique allows insertion of very large bore catheters (8.5 Fr) via small (18gauge) needles.
Technique
The femoral vein is one of the easiest to reach in the human body because of its large size and constant relationship to the femoral artery. The supine patient is placed with the inguinal regions somewhat dependent, and a Valsalva maneuver is performed. The latter maneuver has been shown to increase the width of the vein by one third and nearly doubles its cross-sectional area.4 When time permits, careful surgical preparation of the areas should precede cannulation, as with all intravenous techniques.
Femoral Vein Cannulation
369
Figure 2. Femoral vein external
The right femoral vein is more naturally cannulated by right-handed operators (Figure 3). With the leg slightly externally rotated, a # 1g-gauge hollow-bore needle is inserted just medial to the femoral pulse, at or just below the inguinal ligament. The needle is advanced at a 45” angle with the bevel gently directed superiorly until bony resistance is encountered. Then, with the left hand of the operator braced against the patient’s thigh, the needle and syringe are gradually withdrawn; simultaneously, gentle traction is applied to the plunger. When venous blood returns freely, the operator’s left hand grips the needle hub, and removes the syringe. The wire-guide is then inserted, the needle is removed, and the appropriatesized catheter is advanced over the wire. This technique has been previously described in greater detail.’ If the blood appears to be arterial, the syringe can be removed and pulsatile blood flow can be confirmed. Five to ten minutes of direct pressure should suffice to prevent the formation of hematoma. Reported success rates for catheterization of the femoral vein have been greater than those for the subclavian vein and have been in the 95% to 100% range in patients
landmarks.
with demonstrable pu1ses.s~s~9Our personal experience is similar. Data are extremely limited in pulseless patients, but less success would be expected. Getzen had excellent success in 25 patients admitted to hospitals in Viet Nam with cardiopulmonary arrest secondary to exsanguination, but a recent unpublished civilian CPR experience had a 31% failure rate in 16 catheterizations. Malpositioning is fairly common and appears to be caused by stiff catheter materials that have been stored in circular shapes. When inserted, this type of catheter tends to buckle, to turn on itself, or to seek lateral tributaries of the femoral vein. This occurred in 11 of Moncrief’s 91 patients.2 Shearing of polyethylene through-the-needle catheters and loss of wire-guides have been reported occasionally when improper insertion techniques were used.* In Getzen’s series, no mention was made of improper placement, other than the statement: “Control x-rays were taken to corroborate the position of the catheter tip.“’ Bozzetti” had three catheter misplacements in his 58 patients. In our experience, use of the wire-guide has virtually assured correct placement.
370
Robert H. Dailey
, FEMORAL ARTERY
Figure 3. Femoral vein cannulation
Femoral cannulation with three compartment inflation of the MAST suit is possible, but difficult. Nevertheless, if the abdominal compartment is deflated and peeled away, access is quite convenient. Applications
In emergency medicine, the femoral vein provides an excellent access route for any purpose, especially in the case of patients who are in hypovolemic shock or who have sclerosed peripheral veins secondary to intravenous drug abuse, or for CVP monitoring with catheters that extend above the diaphragm. Much of the recent literature is from dialysis centers. *.‘l Published experience has been excellent; success rates of insertion have been high, and complication rates have been low when large-bore catheters were placed for short periods. For hyperalimentation of patients who have lost subclavian or internal jugular access as a result of thrombosis, silicone catheters have been advanced into the femoral vein via cut-down of the superficial saphenous vein of the thigh.” Small series have reported successful use for durations up to several months.‘3.14
from right side.
Cardiothoracic surgeons have reported extensive use of the femoral vein and artery - with excellent success-in partial and total cardiopulmonary bypass in over 100 patients.15 They cited unfamiliarity with the technique as the principal reason for its infrequent use. Recently, oncologists have begun to use the femoral vein for administration of chemotherapeutic agents. In a recent report, 120 patients had a total of 428 catheter insertions.9 All patients were successfully cannulated. In the latest American Heart Association ACLS Manual, the femoral vein has been recognized and recommended for access in CPR.6 Use of the femoral vein for venous-to-venous resin perfusion of overdoses has been demonstrated to be practical and effective.16 The femoral vein is now used for placement of pulmonary artery catheters. Last, as a route for plasmaphoresis or phlebotomy, the femoral vein appears to be ideal. Complications
The three principal complications of femoral cannulation are thrombosis (with or without pulmonary embolism), arterial hemorrhage, and infection. Although these com-
Femoral Vein Cannulatlon
plications were frequent 25 years ago,‘,2 recently they have diminished markedly. This discrepancy is explainable. The early studies were of chronically ill, elderly patients who were cannulated without strict sterile precautions, who were given sclerosing solutions (25% to 50% dextrose!), and whose catheters were left in place for long periods. In recent studies, more careful attention was paid to aseptic placement technique; the patients were in better general condition; catheters were placed for short periods; and sclerosing solutions were not used. The most dreaded complication of cannulation is thromboembolism. Unfortunately, there are few good data available, probably because of the occult nature of partial venous thrombosis and pulmonary embolism. In five series,“-*’ from the 195Os, polyvinyl tubing was used for long periods (days to months) in very sick patients whose other veins had been exhausted. Although only 5% to 10% developed thrombosis clinically, up to 33% of autopsied patients revealed thrombus formation about the catheters. Venous mural thrombosis and pulmonary embolism were seldom mentioned, however, so that their incidence cannot be assessed. When 25% to 50% dextrose solutions were infused, the incidence of thrombotic complications was almost 50%!’ The experience in recent years has been better. Getzen reported no thrombophlebitis in his patients, 759 soldiers who were cannulated fernorally. ErbarP found no clinical thrombosis in his 2,368 heparinized dialysis patients and only four instances in autopsied patients (v 10 thromboses in 2,494 patients with subclavian catheterization). Bozzettil” identified 1 thromboembolism clinically in 58 patients who were catheterized for long periods. The short-term administration of sclerosing chemotherapeutic agents produced 9 cases of clinical thrombophlebitis (without pulmonary embolism) in 120 patients (428 cannulations).’ Nevertheless, thromboembolism can occur in short-term catheterizations: Lynn et a1,22 reported a major pulmonary embolism in a young woman whose femoral vein was cannulated for only 30 minutes (to sample
371
renal vein renin). She was taking oral contraceptives; this was a possible precipitating factor. Infection of the skin site or septic thrombophlebitis may also oocur. Cases of septic thrombophlebitis were mentioned only occasionally in the studies of the 195Os, but in Moncriefs 91 burn patients, death was documented secondary to this complication in 4 patients.2 A French study looked at the risk of infection in femoral versus subclavian catheters left in for a mean of five days.23 Nineteen percent of femoral catheters were culture-positive as compared with 25% of subclavian and 28% of external jugular catheters. Actual bacteremia occurred in only 2% of their 1,520 catheterizations, but the number of bacteremias secondary to femoral catheters is not mentioned. Getzen reported the following incidence of “infection” in catheterizations: peripheral 3.3%; subclavian 1.1%; and femoral 1.4%. Erban” found no infectious complications in his thousands of short-term dialysis catheterizations. Hemorrhage has not been as significant a problem as thrombosis and infection have been. It was rarely reported in the 1950s. Erban et al8 reported one fatality in an elderly man who hemorrhaged from puncture of an arteriosclerotic plaque, but there were only 18 other recorded hemorrhages in 2,368 heparinized patients. Getzen had a low incidence of “major hematoma,” despite the use of 16gauge needles in patients, 90% of whom were pulseless. Of the major hematomas, 1.6% occurred in peripherals; 0.3% in subclavians, and 1.3% in fernorals. Indeed, although pulselessness probably accounted for many arterial punctures, it probably also protected against significant bleeding. Bozzetti” reported 3 hematomas in 58 patients. The femoral artery is not the only vessel that can be injured. One patient, in whom the femoral vein was catheterized above the inguinal ligament, had the inferior epigastric artery lacerated, with the consequent formation of massive scrotal hematoma.24 Other unusual complications have been reported. Arterial spasm accounted for one case of transient ischemia in the series of
372
Robert H. Dailey
Ladd and Shriner,18 and caused foot gangrene in two young children.3 AV fistula has been reported once,*’ and suspected but not proven in another case.2 Retroperitoneal extravasation of intravenous fluid occurred from several access sites (including the femoral vein) in two infants who were being hyperalimented26; the extravasation was not explainable. Summary Use of the femoral vein for venous cannulation has been described and reviewed. This
vein is large, accessible, has constant anatomic relationships to both surface and deep structures, is readily available in all patients, and is easily and quickly cannulated percutaneously. Although its use has not often been described since earlier reports of serious complications, recent experience suggests that its short-term use may be a simple and safe alternative to other routes. However, the ultimate utility and safety of femoral cannulation awaits greater experience with this technique in emergency medicine.
REFERENCES 1. Bansmer MD, Keith BA, Tesluk MD: Complications following use of indwelling catheters of inferior vena cava. JAMA 1958; 167:1606-1611. 2. Moncrief .I: Femoral catheters. Ann Surg 1958; 147:166-172. 3. Nasbeth DC, Jones JE: Gangrene of the lower extremities of infants after femoral venipuncture. N Engl JA4ed 1963; 268:1003-1005. 4. Junker JA, Totty WC, Stanley RJ, McClennan BL: Computed tomographic confirmation of femoral vein distension with the Valsalva maneuver. Radiology 1983; 1471275. 5. Getzen LC, Pollak EW: Short-term femoral vein Am J Surg 1979; 138:875-877. catheterization. 6. American Heart Associaton, Femoral vein anatomy, in Mclntyre KM, Lews AJ (eds): Texrbook of Advanced Cardiac Life Support, Dallas, TX, American Heart Association, 1981. 7. Dailey RH: Use of wire-guided (Seldinger-type) catheters in the emergency department. Ann Emerg Med 1983; 12:489-492. 8. Erben J, et al: Long-term experience with the technique of subclavian and femoral vein cannulation in hemodialysis. Artificial Organs 1979; 2:241244. 9. Nidus BD, Speyer JL, Bottino J, et al: Repeated femoral vein cannulation for administration of chemotherapeutic agents. Cancer Treat Rep 1983; 67:185-186. 10. Bozzetti F: Percutaneous femoral vein catheterizations, letter. Anaesthesia 1978; 33:761-762. 11. Shaldon S, Chiandussi L, Higgs B: Hemodialysis by percutaneous catheterization of the femoral artery and vein with regional heparinisation. Lancet 1961; 2:857-859. 12. Dronen SC, Yee AS, Tomlanovich MC: Proximal saphenous vein cutdown. Ann Emerg Med 1981; 10:328-330. 13. Weiss Sm. Stewart M, Rosato F: Prolonged central venous catheterization through the saphenous vein. Surg Gynecof Obstef 1982; 154:87-88. 14. LaSala PA, Starker PM, Askanazi J: The saphenous system for long-term parenteral nutrition.
Crit Care Med 1983; 11:378-380. 15. Berger RL, Saini VK, Dargan EL: Clinical applications of femoral vein-to-artery cannulation for mechanical cardiopulmonary support and bypass. Ann Thorac Surg 1973; 15:163-169. 16. Koffler A, Bernstein M, LaSette A, Massry S: Fixed-bed charcoal hemoperfusion - Treatment of drug overdose. Arch Infern Med 1978; 138:16911694. 17. Duffy BJ, Jr: Clinical use of polyethylene tubing for intravenous therapy: Report on 72 cases. Ann Surg 1949; 130:929-936. 18. Ladd M, Schreiner GE: Plastic tubing for intravenous alimentation. JAMA 1951; 145:642-643. 19. Bonner CD: Experience with plastic tubing in prolonged intravenous therapy. NEnglJMed 1951; 245~97-98. 20. Page OC, Stephens JW: Prolonged intravenous alimentation: Use of polyethylene tubing in inferior vena cava or common iliac veins. Northwest Med 1954; 53:596-599. 21. Stoberl R: Der sogenannte Cavakatheter: Technik und eigene Erfahrungen. Wein K/in Wochenschr 1956: 639-641. 22. Lynn KL, Maling TMJ: Case reports: A major pulmonary embolus as a complication of femoral vein catheterization. Br J Radio1 1977; 50:667668. 23. Gertner J, Herman B, Pescio M, Wolff M: Risk of infection in prolonged central venous catheterization. Surg Gynecol Obstet 1979; 149:567-570. 24. Sung JP, Bikangaga AW, Abbott JA: Massive hemorrhage to scrotum from laceration of inferior epigastric artery following percutaneous femoral vein catheterization: Case report. Milit Med 1981; 1461362-363. 25. Fuller TJ, Majoney JJ, Juncos LI, Hawkins RF: Arteriovenous fistula after femoral vein catheterization. JAMA 1976; 236~2943-2944. 26. Spriggs DW, Brantley RE: Thoracic and abdominal extravasation: A complication of hyperalimentation in infants. Am JRoentgeno/ 1977; 128: 419-422.
FEMORAL VEIN CANNULATION:
A REVIEW
Robert H. Dailey, MD Cllnlcal Professor, Unlverslty of Callfornla at San Francisco. and Chief. Emergency MedIcme. Hlghland General Hospital, Oakland, Callfornla Reprint address. Robert H. Dailey, MD, Chief, Emergency Medune. Highland General Hospital, 1411 East 31 st Street. Oakland, CA 94602
Cl Abstract -The femoral vein is an excellent potential venous access site. The technique of cannulation is described and its applications and complications are reviewed. More extensive future use of this technique is necessary to determine its proper role in emergency medicine.
the last 10 years, however, the successful use of the femoral vein for a variety of purposes (principally hemodialysis), warrants a reexamination of the experience in cannulation of this vein.
3 Keywords-femoral
Anatomy
vein; intravenous
lines
Introduction
Venous access in the hypovolemic ill or injured patient continues to challenge the emergency physician’s skills. Traditional access has used catheter-over-needle devices in the superficial veins of the arms, and cutdowns on those same veins or the superficial saphenous vein at the ankle. In the past 20 years, considerable attention has been given to percutaneous catheterization of tne subclavian and internal jugular veins. In the last two to three years, the increasing use of J-wire-guided catheters has allowed use of the external jugular vein. However, the use of the femoral vein has remained relatively neglected, and not without reasons: earlier reports in adults described impressive complications.‘-3 In
Z=ZZXE -
The femoral vein is quite large (12 to 16 mm in diameter).“ Its anatomy is relatively predictable (Figure 1): it arises deep in the thigh, becomes relatively superficial as it crosses the inguinal ligament, then dives deep into the pelvis as the external iliac vein. Below the inguinal ligament, it lies consistently just medial to the femoral artery. However, above the inguinal ligament, it crosses beneath the femoral artery, joining the inferior vena cava to the right of the aorta. The femoral arterial pulse is an extremely useful landmark for locating the vein in the patient with demonstrable pulse. However, in the pulseless patient, cannulation is truly “blind”; therefore, the location of the femoral vein must be related to contiguous bony prominences. Here some confusion exists about the anatomy. Using the
Techniques and Procedures features practical, “how-to” articles of interest to all practicing emergency physicians. This section is coordinated by George Sternbach, MD Stanford University Medical Center.
RECEIVED: 1 June
1984; ACCEPTED: 25 October 367
1984
0736-4679185
$3.00
+ .OO
Robert H.
Dailey
Figure 1. Femoral vein anatomy.
anterior superior iliac spine and the pubic tubercle as external landmarks, different authors describe the location of the artery as (a) at the midpoint of the junction of the medial and middle thirds of a straight line drawn between these two landmarks”; or (6) at the midpoint between those landmarks.6 This confusion may be explained somewhat by the fact that the operator does not enter the femoral vein in a line drawn directly between those two points, but rather inferior to it (Figure 2); nor has anyone actually performed dissections to define these anatomical relationships. In our experience, the femoral artery is found at the inguinal ligament just inferior to the point described in (a) above.
Equipment
Previously, a very large-bore (14-gauge) and long-beveled needle were necessary for catheter-through-needle cannulation; but this unit required that the entire needle bevel be
in the vein for successful catheter-threading. When improperly directed, this large needle could cause serious arterial and pleural punctures. These disadvantages have been lessened by wire-guided (Seldinger) catheter techniques. The “step-up” capability of the Seldinger technique allows insertion of very large bore catheters (8.5 Fr) via small (18gauge) needles.
Technique
The femoral vein is one of the easiest to reach in the human body because of its large size and constant relationship to the femoral artery. The supine patient is placed with the inguinal regions somewhat dependent, and a Valsalva maneuver is performed. The latter maneuver has been shown to increase the width of the vein by one third and nearly doubles its cross-sectional area.4 When time permits, careful surgical preparation of the areas should precede cannulation, as with all intravenous techniques.
Femoral Vein Cannulation
369
Figure 2. Femoral vein external
The right femoral vein is more naturally cannulated by right-handed operators (Figure 3). With the leg slightly externally rotated, a # 1g-gauge hollow-bore needle is inserted just medial to the femoral pulse, at or just below the inguinal ligament. The needle is advanced at a 45” angle with the bevel gently directed superiorly until bony resistance is encountered. Then, with the left hand of the operator braced against the patient’s thigh, the needle and syringe are gradually withdrawn; simultaneously, gentle traction is applied to the plunger. When venous blood returns freely, the operator’s left hand grips the needle hub, and removes the syringe. The wire-guide is then inserted, the needle is removed, and the appropriatesized catheter is advanced over the wire. This technique has been previously described in greater detail.’ If the blood appears to be arterial, the syringe can be removed and pulsatile blood flow can be confirmed. Five to ten minutes of direct pressure should suffice to prevent the formation of hematoma. Reported success rates for catheterization of the femoral vein have been greater than those for the subclavian vein and have been in the 95% to 100% range in patients
landmarks.
with demonstrable pu1ses.s~s~9Our personal experience is similar. Data are extremely limited in pulseless patients, but less success would be expected. Getzen had excellent success in 25 patients admitted to hospitals in Viet Nam with cardiopulmonary arrest secondary to exsanguination, but a recent unpublished civilian CPR experience had a 31% failure rate in 16 catheterizations. Malpositioning is fairly common and appears to be caused by stiff catheter materials that have been stored in circular shapes. When inserted, this type of catheter tends to buckle, to turn on itself, or to seek lateral tributaries of the femoral vein. This occurred in 11 of Moncrief’s 91 patients.2 Shearing of polyethylene through-the-needle catheters and loss of wire-guides have been reported occasionally when improper insertion techniques were used.* In Getzen’s series, no mention was made of improper placement, other than the statement: “Control x-rays were taken to corroborate the position of the catheter tip.“’ Bozzetti” had three catheter misplacements in his 58 patients. In our experience, use of the wire-guide has virtually assured correct placement.
370
Robert H. Dailey
, FEMORAL ARTERY
Figure 3. Femoral vein cannulation
Femoral cannulation with three compartment inflation of the MAST suit is possible, but difficult. Nevertheless, if the abdominal compartment is deflated and peeled away, access is quite convenient. Applications
In emergency medicine, the femoral vein provides an excellent access route for any purpose, especially in the case of patients who are in hypovolemic shock or who have sclerosed peripheral veins secondary to intravenous drug abuse, or for CVP monitoring with catheters that extend above the diaphragm. Much of the recent literature is from dialysis centers. *.‘l Published experience has been excellent; success rates of insertion have been high, and complication rates have been low when large-bore catheters were placed for short periods. For hyperalimentation of patients who have lost subclavian or internal jugular access as a result of thrombosis, silicone catheters have been advanced into the femoral vein via cut-down of the superficial saphenous vein of the thigh.” Small series have reported successful use for durations up to several months.‘3.14
from right side.
Cardiothoracic surgeons have reported extensive use of the femoral vein and artery - with excellent success-in partial and total cardiopulmonary bypass in over 100 patients.15 They cited unfamiliarity with the technique as the principal reason for its infrequent use. Recently, oncologists have begun to use the femoral vein for administration of chemotherapeutic agents. In a recent report, 120 patients had a total of 428 catheter insertions.9 All patients were successfully cannulated. In the latest American Heart Association ACLS Manual, the femoral vein has been recognized and recommended for access in CPR.6 Use of the femoral vein for venous-to-venous resin perfusion of overdoses has been demonstrated to be practical and effective.16 The femoral vein is now used for placement of pulmonary artery catheters. Last, as a route for plasmaphoresis or phlebotomy, the femoral vein appears to be ideal. Complications
The three principal complications of femoral cannulation are thrombosis (with or without pulmonary embolism), arterial hemorrhage, and infection. Although these com-
Femoral Vein Cannulatlon
plications were frequent 25 years ago,‘,2 recently they have diminished markedly. This discrepancy is explainable. The early studies were of chronically ill, elderly patients who were cannulated without strict sterile precautions, who were given sclerosing solutions (25% to 50% dextrose!), and whose catheters were left in place for long periods. In recent studies, more careful attention was paid to aseptic placement technique; the patients were in better general condition; catheters were placed for short periods; and sclerosing solutions were not used. The most dreaded complication of cannulation is thromboembolism. Unfortunately, there are few good data available, probably because of the occult nature of partial venous thrombosis and pulmonary embolism. In five series,“-*’ from the 195Os, polyvinyl tubing was used for long periods (days to months) in very sick patients whose other veins had been exhausted. Although only 5% to 10% developed thrombosis clinically, up to 33% of autopsied patients revealed thrombus formation about the catheters. Venous mural thrombosis and pulmonary embolism were seldom mentioned, however, so that their incidence cannot be assessed. When 25% to 50% dextrose solutions were infused, the incidence of thrombotic complications was almost 50%!’ The experience in recent years has been better. Getzen reported no thrombophlebitis in his patients, 759 soldiers who were cannulated fernorally. ErbarP found no clinical thrombosis in his 2,368 heparinized dialysis patients and only four instances in autopsied patients (v 10 thromboses in 2,494 patients with subclavian catheterization). Bozzettil” identified 1 thromboembolism clinically in 58 patients who were catheterized for long periods. The short-term administration of sclerosing chemotherapeutic agents produced 9 cases of clinical thrombophlebitis (without pulmonary embolism) in 120 patients (428 cannulations).’ Nevertheless, thromboembolism can occur in short-term catheterizations: Lynn et a1,22 reported a major pulmonary embolism in a young woman whose femoral vein was cannulated for only 30 minutes (to sample
371
renal vein renin). She was taking oral contraceptives; this was a possible precipitating factor. Infection of the skin site or septic thrombophlebitis may also oocur. Cases of septic thrombophlebitis were mentioned only occasionally in the studies of the 195Os, but in Moncriefs 91 burn patients, death was documented secondary to this complication in 4 patients.2 A French study looked at the risk of infection in femoral versus subclavian catheters left in for a mean of five days.23 Nineteen percent of femoral catheters were culture-positive as compared with 25% of subclavian and 28% of external jugular catheters. Actual bacteremia occurred in only 2% of their 1,520 catheterizations, but the number of bacteremias secondary to femoral catheters is not mentioned. Getzen reported the following incidence of “infection” in catheterizations: peripheral 3.3%; subclavian 1.1%; and femoral 1.4%. Erban” found no infectious complications in his thousands of short-term dialysis catheterizations. Hemorrhage has not been as significant a problem as thrombosis and infection have been. It was rarely reported in the 1950s. Erban et al8 reported one fatality in an elderly man who hemorrhaged from puncture of an arteriosclerotic plaque, but there were only 18 other recorded hemorrhages in 2,368 heparinized patients. Getzen had a low incidence of “major hematoma,” despite the use of 16gauge needles in patients, 90% of whom were pulseless. Of the major hematomas, 1.6% occurred in peripherals; 0.3% in subclavians, and 1.3% in fernorals. Indeed, although pulselessness probably accounted for many arterial punctures, it probably also protected against significant bleeding. Bozzetti” reported 3 hematomas in 58 patients. The femoral artery is not the only vessel that can be injured. One patient, in whom the femoral vein was catheterized above the inguinal ligament, had the inferior epigastric artery lacerated, with the consequent formation of massive scrotal hematoma.24 Other unusual complications have been reported. Arterial spasm accounted for one case of transient ischemia in the series of
372
Robert H. Dailey
Ladd and Shriner,18 and caused foot gangrene in two young children.3 AV fistula has been reported once,*’ and suspected but not proven in another case.2 Retroperitoneal extravasation of intravenous fluid occurred from several access sites (including the femoral vein) in two infants who were being hyperalimented26; the extravasation was not explainable. Summary Use of the femoral vein for venous cannulation has been described and reviewed. This
vein is large, accessible, has constant anatomic relationships to both surface and deep structures, is readily available in all patients, and is easily and quickly cannulated percutaneously. Although its use has not often been described since earlier reports of serious complications, recent experience suggests that its short-term use may be a simple and safe alternative to other routes. However, the ultimate utility and safety of femoral cannulation awaits greater experience with this technique in emergency medicine.
REFERENCES 1. Bansmer MD, Keith BA, Tesluk MD: Complications following use of indwelling catheters of inferior vena cava. JAMA 1958; 167:1606-1611. 2. Moncrief .I: Femoral catheters. Ann Surg 1958; 147:166-172. 3. Nasbeth DC, Jones JE: Gangrene of the lower extremities of infants after femoral venipuncture. N Engl JA4ed 1963; 268:1003-1005. 4. Junker JA, Totty WC, Stanley RJ, McClennan BL: Computed tomographic confirmation of femoral vein distension with the Valsalva maneuver. Radiology 1983; 1471275. 5. Getzen LC, Pollak EW: Short-term femoral vein Am J Surg 1979; 138:875-877. catheterization. 6. American Heart Associaton, Femoral vein anatomy, in Mclntyre KM, Lews AJ (eds): Texrbook of Advanced Cardiac Life Support, Dallas, TX, American Heart Association, 1981. 7. Dailey RH: Use of wire-guided (Seldinger-type) catheters in the emergency department. Ann Emerg Med 1983; 12:489-492. 8. Erben J, et al: Long-term experience with the technique of subclavian and femoral vein cannulation in hemodialysis. Artificial Organs 1979; 2:241244. 9. Nidus BD, Speyer JL, Bottino J, et al: Repeated femoral vein cannulation for administration of chemotherapeutic agents. Cancer Treat Rep 1983; 67:185-186. 10. Bozzetti F: Percutaneous femoral vein catheterizations, letter. Anaesthesia 1978; 33:761-762. 11. Shaldon S, Chiandussi L, Higgs B: Hemodialysis by percutaneous catheterization of the femoral artery and vein with regional heparinisation. Lancet 1961; 2:857-859. 12. Dronen SC, Yee AS, Tomlanovich MC: Proximal saphenous vein cutdown. Ann Emerg Med 1981; 10:328-330. 13. Weiss Sm. Stewart M, Rosato F: Prolonged central venous catheterization through the saphenous vein. Surg Gynecof Obstef 1982; 154:87-88. 14. LaSala PA, Starker PM, Askanazi J: The saphenous system for long-term parenteral nutrition.
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