Avoiding the femoral vein in central venous cannulation: an outdated practice

Contemporary data on central venous cannulation shows safety advantages to using the femoral vein in some cases.


Central venous catheterization is a commonly performed procedure in hospitalized patients, and current guidelines specifically recommend against placing central venous catheters (CVCs) in the femoral vein, based on historical data suggesting increased infectious complications. However, contemporary data, gathered after the broad adoption of routine sterile-access techniques, shows safety advantages to using the femoral vein in some cases.

Consider the example of a 48-year-old man admitted to the ICU with acute pancreatitis. Despite ongoing volume resuscitation, the patient continued to deteriorate and required the initiation of vasopressor support. To safely administer these medications, a CVC was placed. The femoral vein was avoided, based on the Institute for Healthcare Improvement central line bundle, and an ultrasound-guided internal jugular venous catheter was placed without complication. Seventy-two hours later, the patient began spiking fevers. Peripheral and central line drawn blood cultures grew gram-positive cocci in clusters. Did the site of the CVC impact the patient's risk of developing a central line-associated bloodstream infection (CLABSI)?

Background

Up to 8% of hospitalized patients receive a central line, with approximately 5 million of these devices being placed yearly (11. How-to Guide: Prevent Central Line-Associated Bloodstream Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. Available online. , 22. Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med. 2002;30:454-60. [PMID: 11889329]). In 2011, the CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) published “Guidelines for the Prevention of Intravascular Catheter-Related Infections” (33. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123-33. [PMID: 12646670]). This publication marked the first time a national guideline specifically recommended avoiding femoral vein access in adults. Prior to this, the 2002 guidelines by the same committee stated that there was a presumption of infectious risk but that this had never been substantiated with evidence (44. CDC. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Accessed on Aug. 21, 2017. ).

In 2012, shortly after the CDC/HICPAC Guidelines were released, the Institute for Healthcare Improvement published recommendations on the prevention of CLABSIs, which came to be known as the central line bundle (55. CDC. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002. Accessed on Aug. 21, 2017. ), and recommended that the femoral vein access site be avoided in adult patients. This recommendation was based on multiple studies that found evidence for (66. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, et al; French Catheter Study Group in Intensive Care. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001;286:700-7. [PMID: 11495620], 77. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998;19:842-5. [PMID: 9831940], 88. Lorente L, Henry C, Martín MM, Jiménez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005;9:R631-5. [PMID: 16280064]) and against (99. Parienti JJ, Thirion M, Mégarbane B, Souweine B, Ouchikhe A, Polito A, et al; Members of the Cathedia Study Group. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008;299:2413-22. [PMID: 18505951]) site selection affecting infectious risk. Other novel recommendations in the central line bundle included maximal barrier precautions (sterile technique and full-body draping) and daily review of line necessity to encourage early removal. Since the initiation of the central line bundle, numerous studies have failed to find a relationship between femoral vein CVC placement and increased risk for infection (1010. Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, Gros A, et al; 3SITES Study Group. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373:1220-9. [PMID: 26398070], 1111. Parienti JJ, du Cheyron D, Timsit JF, Traoré O, Kalfon P, Mimoz O, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults. Crit Care Med. 2012;40:1627-34. [PMID: 22511140], 1212. Timsit JF, Bouadma L, Mimoz O, Parienti JJ, Garrouste-Orgeas M, Alfandari S, et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med. 2013;188:1232-9. [PMID: 24127770], 1313. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012;40:2479-85. [PMID: 22809915], 1414. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al; Society for Healthcare Epidemiology of America. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35:753-71. [PMID: 24915204]).

Evidence against using the femoral vein

Historically, the risk for CVC infection was thought to correlate with the bacterial burden of the overlying skin. Early data supported this supposition. A 1998 trial comparing sites of CVC placement showed an increase in catheter contamination, based on positive growth of the tip culture after removal, with femoral vein placement relative to subclavian vein placement (hazard ratio [HR], 4.2; P<0.001) (77. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998;19:842-5. [PMID: 9831940]). A randomized controlled trial in 2001 had similar results, with an increase for all infectious complications with femoral vein versus subclavian vein access (HR, 4.83; P<0.001), specifically an increase in clinical sepsis (4.4% vs. 1.5%; P=0.07) (66. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, et al; French Catheter Study Group in Intensive Care. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001;286:700-7. [PMID: 11495620]). Last, a 2005 trial demonstrated an association between site of insertion and risk of developing a catheter-related bloodstream infection, defined by positive blood culture, systemic signs of infection, and positive catheter tip culture. This trial showed a higher incidence of infection with femoral vein access relative to both jugular vein (8.34 vs. 2.99 infections per 1,000 catheter-days; P=0.002) and subclavian vein sites (8.34 vs. 0.97 infections per 1,000 catheter-days; P<0.001) (88. Lorente L, Henry C, Martín MM, Jiménez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005;9:R631-5. [PMID: 16280064]).

Evidence for using the femoral vein

Studies performed after the adoption of the IHI's central line bundle have not shown the same site-related differences in risk of infection. In a meta-analysis of 10 studies, femoral vein access sites were found to have greater infectious risk relative to subclavian vein access sites; however, internal jugular vein sites also had a similarly increased risk of infection relative to subclavian vein sites (1111. Parienti JJ, du Cheyron D, Timsit JF, Traoré O, Kalfon P, Mimoz O, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults. Crit Care Med. 2012;40:1627-34. [PMID: 22511140]). A multicenter study found no difference in catheter-related bloodstream infection, major catheter-related infection, or colonization between internal jugular vein and femoral vein CVCs (1212. Timsit JF, Bouadma L, Mimoz O, Parienti JJ, Garrouste-Orgeas M, Alfandari S, et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med. 2013;188:1232-9. [PMID: 24127770]). A 2012 meta-analysis failed to demonstrate any significant difference in infectious risk between femoral, internal jugular, and subclavian vein sites. This meta-analysis also showed that the risk of femoral venous line infections was statistically correlated with the year of publication, as there was a higher risk in the earlier studies (1313. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012;40:2479-85. [PMID: 22809915]). Last, in the largest multicenter trial published to date, subclavian vein placement was associated with reduced infectious risk relative to internal jugular or femoral vein sites, which had similar levels of risk. This study was also notable for identifying femoral vein access as having a significant decrease in mechanical complications compared to subclavian vein access, with complications defined by pneumothorax requiring chest tube, bleeding requiring transfusion of at least two units of blood, or hematoma requiring transfusion or operative intervention. However, there was only a trend toward decreased complications with the femoral vein compared to the internal jugular vein (1010. Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, Gros A, et al; 3SITES Study Group. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373:1220-9. [PMID: 26398070]).

Specific patient populations

The safest point of access may vary for specific patient populations. A randomized, controlled multicenter trial found no difference in the infectious risk between jugular and femoral vein access for the study population as a whole, but a subgroup of patients with a high body mass index (defined as >28.4 kg/m2) had fewer infections with an internal jugular versus femoral vein site (HR, 0.4; P<0.001) (99. Parienti JJ, Thirion M, Mégarbane B, Souweine B, Ouchikhe A, Polito A, et al; Members of the Cathedia Study Group. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008;299:2413-22. [PMID: 18505951]). This study was performed in 2008, prior to the adoption of the IHI's bundle, and the same group of researchers has not found corroborating data in subsequent studies (1010. Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, Gros A, et al; 3SITES Study Group. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373:1220-9. [PMID: 26398070], 1111. Parienti JJ, du Cheyron D, Timsit JF, Traoré O, Kalfon P, Mimoz O, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults. Crit Care Med. 2012;40:1627-34. [PMID: 22511140]). One multicenter trial also demonstrated an increased risk of catheter colonization with femoral vein access compared to internal jugular vein access in female patients (HR, 0.39; P<0.001), but there was no increase in catheter-related bloodstream infection (defined as positive catheter-tip culture with positive peripheral culture of the same organism) or major catheter-related infection (defined as catheter-related sepsis) (1212. Timsit JF, Bouadma L, Mimoz O, Parienti JJ, Garrouste-Orgeas M, Alfandari S, et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med. 2013;188:1232-9. [PMID: 24127770]). Multiple studies have found no evidence that women have a higher risk for infections with femoral vein catheters (88. Lorente L, Henry C, Martín MM, Jiménez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005;9:R631-5. [PMID: 16280064], 99. Parienti JJ, Thirion M, Mégarbane B, Souweine B, Ouchikhe A, Polito A, et al; Members of the Cathedia Study Group. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008;299:2413-22. [PMID: 18505951], 1010. Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, Gros A, et al; 3SITES Study Group. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373:1220-9. [PMID: 26398070]).

Mechanical considerations

An often-proffered reason for the avoidance of femoral access is mobility restriction. This restriction is more a historical concern given the flexibility of modern catheter materials and improved retention devices. Contemporary data does not support restricting the mobility of patients with a femoral catheter. In a prospective study from 2013, 101 patients with a femoral vein catheter received a total of 253 physical therapy sessions including walking, sitting, supine cycle ergometry, and in-bed exercises without a single adverse event (1515. Damluji A, Zanni JM, Mantheiy E, Colantuoni E, Kho ME, Needham DM. Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit. J Crit Care. 2013;28:535.e9-15. [PMID: 23499419]). An observational study from 2013 followed 77 patients with femoral catheters undergoing 210 physical therapy sessions, including sitting, standing, transferring, and walking, and it had a mechanical and thrombotic complication rate of zero (1616. Perme C, Nalty T, Winkelman C, Kenji Nawa R, Masud F. Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: A prospective observational study. Cardiopulm Phys Ther J. 2013;24:12-7. [PMID: 23801900]).

Conclusions

With these data in mind, clinicians should individually assess each patient prior to CVC site selection. The patient described in the clinical scenario above did not have his risk of infection decreased by selectively catheterizing the internal jugular vein instead of the femoral vein and instead may have been subjected to an increased risk of mechanical complications. Factors that may increase the risk of mechanical complications (history of multiple punctures in that region, clinician competency, cachexia, chronic obstructive pulmonary disease), thrombotic complications (malignancy, liver disease, and blood dyscrasias), and infectious risk (immune compromise, chosen access site, and emergent nature of line) should all be assessed.

Although there is some data that femoral access in female or obese patients can increase the risk of infection, this data is inconclusive and has not been supported by subsequent studies looking specifically at these subgroups. Thus, avoiding femoral lines based on gender or body mass index is not appropriate. Furthermore, femoral central lines have been shown to be safe in patients receiving physical therapy, so mobility restriction no longer has to be standard.

Ultimately, the site for a CVC should be selected after consideration of all relevant factors to provide the safest possible central access for the patient. The femoral vein site can be safely utilized for central venous access in the appropriate patient population and need not be universally avoided based on historical data.