What is the recommended procedure for central line placement in the femoral vein of an adult patient, considering potential complications and comorbidities such as bleeding disorders or anticoagulant therapy?

Femoral Vein Central Line Placement: Procedure and Considerations

Critical Site Selection Caveat

The femoral vein should be avoided for central venous access in adult patients whenever possible, as it carries significantly higher risks of infection and thrombosis compared to upper body sites. 1, 2 Multiple high-quality guidelines consistently recommend against femoral access: the CDC states to "avoid using the femoral vein for central venous access in adult patients" (Category 1A recommendation), and the International Society for Infectious Diseases confirms that femoral insertion sites increase CLABSI risk. 1

However, when femoral access is clinically necessary (e.g., contraindications to upper body sites, emergency situations, or specific surgical requirements), the following procedure should be followed:

Pre-Procedure Assessment

Patient Positioning

• Place the patient supine with the leg slightly abducted and externally rotated to optimize access to the femoral triangle. 1
• Consider Trendelenburg positioning if clinically appropriate, as this increases venous distension (though this is more critical for upper body sites). 1

Ultrasound Evaluation - Critical Diagnostic Step

• Apply low abdominal compression during pre-procedural ultrasound assessment to increase femoral vein diameter and facilitate visualization. 3
• If the femoral vein does not increase in diameter with abdominal compression, suspect iliac vein thrombosis and select an alternative access site. 3 This lack of response is a red flag indicating central venous obstruction.
• Use a high-frequency linear transducer (5-15 MHz) to evaluate vessel size, depth, patency, and absence of thrombosis. 4, 5
• Note that inguinal structures are far less echogenic than neck vessels, making visualization more challenging. 3

Coagulopathy Considerations

• Routine correction of coagulopathy is only recommended if: 2
  • Platelet count <50 × 10⁹/L
  • aPTT >1.3 times normal
  • INR >1.8

Infection Prevention Bundle

Maximal Sterile Barrier Precautions

• Apply full maximal sterile barrier precautions including: 1, 2
  • Sterile cap
  • Mask covering both mouth and nose
  • Sterile gown
  • Sterile gloves
  • Sterile full-body patient drape

Skin Preparation

• Prepare skin with alcoholic chlorhexidine solution containing minimum 2% CHG, allowing it to dry completely before puncture. 1
• If chlorhexidine is contraindicated, use povidone-iodine or alcohol as alternatives, ensuring the solution contains alcohol unless contraindicated. 1

Catheter Insertion Technique

Ultrasound-Guided Approach

• Use real-time (dynamic) ultrasound guidance for all femoral vein cannulations. 1, 4, 6 This reduces arterial punctures, decreases procedure time, and increases success rates. 4, 7
• Maintain low abdominal compression during puncture to keep the vein distended. 3
• Either transverse (short-axis) or longitudinal (long-axis) approach may be used based on operator preference and experience. 4

Needle and Wire Technique

• For femoral approach, select either thin-wall needle (Seldinger) or catheter-over-the-needle (Modified Seldinger) technique based on clinical situation and operator experience. 1
• Visualize the needle tip in the target vein before advancing the guidewire. 4
• After threading the wire, confirm venous placement using ultrasound visualization of the wire in the vein, manometry, or pressure-waveform analysis before dilating or inserting the large-bore catheter. 1

Catheter Selection

• Select the smallest catheter diameter appropriate for the clinical indication. 1
• Use the minimum number of lumens essential for patient management. 1, 2

Catheter Tip Positioning

• The catheter tip must be positioned in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium, regardless of insertion site. 1, 8
• Confirm tip position with post-procedure chest X-ray or real-time imaging during the procedure. 1

Post-Procedure Management

Immediate Verification

• Confirm all guidewire has been removed by verifying its presence in the procedural field. 1
• If complete guidewire is not found, obtain chest radiography to rule out retained wire. 1

Dressing and Maintenance

• Apply chlorhexidine-containing dressings for patients over 2 months of age to reduce CLABSI risk. 1
• Replace transparent dressings at least every 7 days; replace gauze dressings every 2 days. 1
• Replace immediately if dressing becomes soiled, loose, or damp. 1

Daily Assessment

• Evaluate the insertion site daily by palpation through the dressing to detect tenderness or signs of infection. 1, 2
• Perform hand hygiene before and after any contact with the catheter or site. 2

Critical Complications to Monitor

Infectious Complications

• Femoral site carries the highest infection risk among all central venous access sites due to proximity to the groin and difficulty maintaining clean exit site. 1
• Monitor for signs of exit site infection, tunnel infection, or systemic CLABSI. 1

Thrombotic Complications

• Femoral access is associated with significantly higher rates of catheter-related venous thrombosis compared to upper body sites. 1
• This risk is particularly elevated with prolonged catheter dwell time. 1

Mechanical Complications

• Arterial puncture is the most common mechanical complication with femoral access. 7
• Ultrasound guidance significantly reduces this risk. 4, 7

When to Remove

• Remove the femoral catheter as soon as clinically feasible and replace with an upper extremity site. 1
• Promptly remove any catheter that is no longer essential. 1, 2
• Remove immediately if signs of infection, malfunction, or thrombosis develop. 1, 2