How to make femoral veins more prominent during central venous (Central Venous Catheterization) cannulation?

Making Femoral Veins More Prominent During Central Venous Cannulation

Apply low abdominal compression to increase femoral vein diameter and facilitate successful puncture. 1

Primary Technique: Low Abdominal Compression

• Low abdominal compression is the evidence-based maneuver specifically recommended to make femoral veins more prominent during cannulation. 1
• This technique works by increasing venous return and distending the femoral vein, thereby increasing its cross-sectional area and improving visualization under ultrasound. 1
• The compression should be applied to the lower abdomen during the pre-procedural ultrasound assessment and maintained during puncture. 1

Critical Diagnostic Point

• If the femoral vein does not increase in diameter with abdominal compression, suspect iliac vein thrombosis and consider an alternative access site. 1
• This lack of response is a red flag indicating more central venous obstruction that will likely result in failed catheter placement. 1

Patient Positioning

• Place the patient in Trendelenburg position to distend the vein and increase its cross-sectional area. 2
• This positioning increases venous filling and makes the target vessel larger and easier to cannulate. 2
• The leg should be slightly abducted and externally rotated to optimize access to the femoral triangle. 3

Ultrasound-Guided Approach (Mandatory)

• Real-time ultrasound guidance should be used for all femoral vein cannulations, as it improves success rates and reduces complications. 1
• Ultrasound allows direct visualization of the vein diameter, patency, and response to compression maneuvers. 1
• The puncture should be performed close to the inguinal ligament at the level of the common femoral artery. 1

Technical Ultrasound Considerations

• Structures in the inguinal region are far less echogenic than in the neck region, making visualization more challenging. 1
• Use a high-frequency linear array probe (5-15 MHz) for optimal visualization of superficial structures. 1
• Pre-procedural ultrasound assessment is critical to evaluate vein patency, diameter, and anatomic variations before attempting puncture. 1

Common Pitfalls to Avoid

• Do not proceed with femoral cannulation if the vein appears thrombosed or does not distend with compression. 1
• Avoid excessive probe pressure during ultrasound examination, as this can compress the vein and make it appear smaller or collapsed. 1
• The femoral site carries higher infection risk than internal jugular or subclavian sites and should be avoided when other options are available. 2, 4

Procedural Algorithm

1. Position patient in Trendelenburg with leg slightly abducted and externally rotated. 2, 3
2. Perform pre-procedural ultrasound to assess vein patency, diameter, and anatomic relationship to the femoral artery. 1, 5
3. Apply low abdominal compression and observe for vein distension on ultrasound. 1
4. If vein does not distend, suspect thrombosis and select alternative site. 1
5. Puncture at the level of the inguinal ligament using real-time ultrasound guidance. 1
6. Confirm venous placement before dilation and catheter insertion. 1, 5

Special Population Considerations

• In infants and neonates, femoral vein visualization is particularly difficult due to poor echogenicity of inguinal structures. 1
• Pediatric patients require meticulous ultrasound technique and may benefit from gel standoff devices to avoid vein compression. 1
• The external diameter of the catheter should not exceed one-third of the internal diameter of the vein to minimize thrombosis risk. 1