Central Venous Catheter (CVC) Insertion – Femoral Vein

Central venous catheterization (CVC) via the femoral vein is another site for obtaining central venous access. While it is generally less preferred than internal jugular or subclavian vein access due to a higher risk of infection, it can be a useful alternative in certain situations.

I. Indications

Femoral vein CVC insertion is indicated in the following scenarios:

• Emergency access: When internal jugular or subclavian vein access is not readily available or contraindicated in emergency situations.
• Contraindications to upper extremity access: Conditions such as subclavian or internal jugular vein thrombosis, chest wall trauma, or mechanical ventilation with high PEEP.
• Difficult access: In patients with altered anatomy or other factors that make upper extremity access challenging.
• Temporary access: For short-term needs, as femoral lines have a higher risk of infection with prolonged use.

II. Contraindications

There are contraindications to femoral vein CVC insertion that you should keep in mind.

• Absolute contraindications:
  • Infection at the insertion site.
  • Thrombosis of the femoral vein.
• Relative contraindications:
  • Altered anatomy (e.g., due to prior surgery or trauma).
  • Coagulopathy.
  • Presence of an abdominal binder or other device that would interfere with site access or catheter maintenance.
  • Morbid obesity.

III. Procedure

Here are the steps for femoral vein CVC insertion:

• Preparation:
  • Explain the procedure to the patient and obtain informed consent.
  • Gather necessary equipment: CVC kit, sterile gloves, gown, mask, drapes, antiseptic solution (chlorhexidine), local anesthetic (lidocaine), and ultrasound machine (if available).
  • Position the patient supine.
  • Expose the patient’s groin area.
• Sterile technique:
  • Perform hand hygiene and apply sterile gloves, gown, and mask.
  • Clean the insertion site with chlorhexidine. Use wide circles.
  • Apply sterile drapes to create a sterile field.
• Vessel identification:
  • Anatomical landmarks:
    • Identify the femoral artery pulse. Remember the mnemonic “NAVEL” (from lateral to medial: Nerve, Artery, Vein, Empty space, Lymph node). The femoral vein lies medial to the femoral artery.
    • The insertion site is typically 1-2 cm below the inguinal ligament, medial to the femoral artery.
  • Ultrasound guidance:
    • Use ultrasound to visualize the femoral vein and artery. The vein is compressible, while the artery is pulsatile and less compressible.
    • This is the preferred method as it increases success rates and reduces complications.
• Local anesthesia:
  • Infiltrate the skin and subcutaneous tissues with lidocaine. If using ultrasound, perform this under ultrasound guidance.
• Venipuncture:
  • Insert the introducer needle 1-2 cm below the inguinal ligament, medial to the femoral artery (or under ultrasound guidance).
  • Advance the needle slowly, aiming towards the umbilicus, while applying gentle negative pressure to the syringe.
  • Confirm venous blood return.
• Guidewire insertion:
  • Stabilize the needle and introduce the guidewire into the vein.
  • Advance the guidewire smoothly. Do not force it.
• Catheter insertion:
  • Remove the needle and dilate the tract if necessary.
  • Thread the CVC over the guidewire and advance it to the desired depth. Generally, advance the catheter 15-20 cm in adults.
• Confirmation and securement:
  • Remove the guidewire.
  • Aspirate and flush all lumens of the catheter to confirm patency.
  • Secure the catheter to the skin using sutures or an adhesive securement device. Due to the location, meticulous securement is crucial to prevent dislodgement.
  • Apply a sterile dressing to the insertion site.
  • Obtain a chest X-ray to confirm catheter placement and rule out complications (though the catheter tip will be in the iliac or common femoral vein, not the SVC).

IV. Complications

Complications associated with femoral vein CVC insertion include:

• Infection: The femoral site has a higher risk of infection compared to upper extremity sites.
• Thrombosis: Risk of deep vein thrombosis (DVT) in the femoral vein.
• Hematoma.
• Arterial puncture.
• Retroperitoneal hemorrhage: Rare but potentially life-threatening.
• Catheter malposition.