Placement of femoral venous catheters

INTRODUCTION — Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [1-4]. Although femoral vein cannulation is often considered less desirable due to higher complication rates, the femoral veins remain a reliable central venous access site, particularly under urgent or emergency circumstances [5,6]. This access site is often preferred for temporary hemodialysis access. Femoral venous access also facilitates introduction of venous devices (eg, inferior vena cava filter, pulmonary artery catheter, extracorporeal membrane oxygenation [ECMO] cannula, iliac venous stent).

The initial selection of central venous access site and type of device are reviewed separately. (See "Central venous access: Device and site selection in adults" and "Central venous access in adults: General principles", section on 'Device and site selection'.)

Once a femoral access site has been selected as the best appropriate site, this topic guides the placement.

Other considerations, complications of venous access, and issues related to other access sites are discussed elsewhere. (See "Central venous access in adults: General principles" and "Central venous catheters: Overview of complications and prevention in adults" and "Placement of jugular venous catheters" and "Placement of subclavian venous catheters".)

FEMORAL VEIN ANATOMY — The femoral vein is the major deep vein of the lower extremity. The vessel traverses the thigh and takes a superficial course at the femoral triangle before passing beneath the inguinal ligament into the pelvis as the external iliac vein (figure 1A-B). The hip joint and psoas muscle lie directly deep to the femoral neurovascular bundle at the level of the inguinal ligament.

Within the femoral triangle, the common femoral vein is enclosed within the femoral sheath, where it lies medial to the femoral artery. The common femoral vein receives several tributaries within this region, including the great saphenous and anterior saphenous veins (figure 2). These veins can be inadvertently cannulated during the procedure and initially misinterpreted as femoral vein cannulation. Lower extremity venous anatomy is discussed in detail separately. (See "Classification of lower extremity chronic venous disorders", section on 'Anatomy (The "A" component of CEAP)'.)

Femoral artery pulsation provides a useful landmark to guide cannulation site selection (picture 1). The midinguinal point lying halfway between the anterior superior iliac spine and pubic tubercle approximates the point where the external iliac artery continues under the inguinal ligament as the femoral artery and provides an important reference point during cardiac arrest or in the absence of a palpable femoral pulse (picture 2). The femoral vein lies medial to this point and the adjacent femoral artery. The inguinal groin crease approximates the inguinal ligament and is also an important procedure landmark. Vessel instrumentation inferior to this point is strategically recommended to target the most superficial point of the femoral vein course and to avoid difficulty recognizing and compressing bleeding complications associated with iliac vein or artery puncture.

GENERAL PREPARATION — General considerations for patient preparation, including catheter and access site selection, monitoring and sedation, measures to control infection, and consent, are discussed elsewhere. (See "Central venous access in adults: General principles", section on 'General preparation'.)

Equipment — Femoral venous catheters are placed using a modified Seldinger technique in a series of defined steps, usually using a prefabricated kit containing all essential materials. These supplies are described in the table (table 1) [7]. For nontunneled catheters, the steps for central venous catheterization are described in the table (table 2). For tunneled catheters and other devices, the steps are similar except that a sheath is placed over the guidewire and the catheter (or other device such as pacemaker leads, venous filter) is placed through the sheath, which is then removed.

Prior to the placement of femoral venous catheters, assemble the following equipment:

●Ultrasound machine (see "Basic principles of ultrasound-guided venous access", section on 'Ultrasound machine')

●Sterile ultrasound transducer gel

●Central line kit with intravenous catheter (size and length based upon diameter and depth of vein)

●Sterile drapes, gloves, gown, surgical mask, and cap

●Topical antiseptic (eg, 2% chlorhexidine solution) (see "Overview of control measures for prevention of surgical site infection in adults", section on 'Skin antisepsis')

●Local anesthetic (see "Clinical use of topical anesthetics in children" and "Subcutaneous infiltration of local anesthetics")

●Isotonic saline and/or heparin for flushing the catheter

●Transparent adhesive dressing, tape

●Intravenous tubing and connectors (eg, needleless Luer connector, three-way stopcock)

Although any length of central venous catheter can be used at the femoral site, longer (eg, 24 cm) catheters are recommended for hemodialysis to allow distal tip placement in the inferior vena cava to achieve adequate flow during hemodialysis [8,9].

The proper functioning of any fluoroscopic equipment should be verified. Fluoroscopy is rarely needed for temporary femoral venous access devices but is necessary for placing inferior vena cava filters or other venous devices (eg, venous stents) and may be useful when altered venous anatomy is encountered.

Skin preparation — For femoral venous access, a wide skin preparation encompasses the anterior and medial surfaces of the proximal thigh and extends superior to low abdominal wall. Hair should be clipped from the access site prior to skin preparation. Clipping is preferred to shaving [10]. A chlorhexidine-alcohol skin antiseptic solution should be applied to the access site and allowed to dry prior to draping the patient [11]. An additional preparation kit may be required for those that contain only iodine solutions, as chlorhexidine skin antisepsis is superior at reducing short-term catheter-related infection. (See "Central venous access in adults: General principles", section on 'Aseptic technique'.)

Positioning — Correct positioning facilitates vein cannulation.

The clinician should position the patient's bed or procedure table at a comfortable height. The procedure is generally performed while standing on the same side as the target access site. Alternatively, some operators reach across the patient to cannulate the contralateral femoral vein (eg, right-handed operator cannulating the left femoral vein from the patient's right side).

The patient should be positioned supine. The target leg is abducted and externally rotated 15 degrees to open the femoral triangle. Elevation of the buttock with rolled sheets or a firm pillow facilitates exposure in some patients. Hospital air mattress beds should be positioned flat and maximally inflated to avoid flexion of the patient hips.

Most patients can be safely positioned supine [12,13]. However, critically ill patients and patients with obesity may develop respiratory compromise in the supine position and require close monitoring. Head-up positioning (ie, reverse Trendelenburg) may augment the cross-sectional area of the femoral vein, but the effect is not universal [14,15]. Some patients may require anesthesia with a controlled airway for safe placement of central venous catheters and devices. (See "Anesthesia for the patient with obesity", section on 'Patient positioning'.)

FEMORAL VEIN CANNULATION

Dynamic ultrasound-guided femoral access — When equipment and expertise are available, we recommend that children and adults undergoing cannulation of the femoral vein have the procedure guided by ultrasound rather than by using anatomic landmarks alone. A systematic review confirmed that ultrasound increased first-attempt and overall femoral access site success [16]. The basic principles of ultrasound for guiding venous access are discussed in detail elsewhere. (See "Central venous access in adults: General principles", section on 'Femoral veins'.)

When using ultrasound to guide femoral venous access, the following steps should be performed (table 2):

●Confirm vein course, patency, and position relative to surface landmarks.

●Prepare the site with antiseptic cleansing and a sterile drape (central line). (See 'General preparation' above.)

●Place the ultrasound gel and probe into a sterile sheath.

●Apply sterile ultrasound conduction medium (eg, water-soluble lubricant) to the external probe cover.

●Identify the femoral vein and center the image on the ultrasound screen (transverse view) (picture 3) or obtain a longitudinal view, using care to distinguish veins from arteries (image 1). (See "Basic principles of ultrasound-guided venous access", section on 'Ultrasound evaluation of vessels' and "Basic principles of ultrasound-guided venous access", section on 'Transducer orientation'.)

●Infiltrate the skin at the intended puncture site with 1% lidocaine.

●Insert the needle (preferably echogenic needle) loaded onto a syringe into the skin and slowly advance toward the vein. (See 'Access techniques' below.)

•If the needle tip is difficult to see using the transverse view, gently move the needle in and out to help identify the needle tip. In the transverse view, it is important to adjust the ultrasound beam to focus on the tip of the needle rather than the shaft. Failure to do so can lead to inadvertent puncture of deeper structures.

•If using the longitudinal view, try to directly observe the needle penetrate the vein on the ultrasound monitor (image 2).

•While maintaining negative pressure on the syringe, advance the needle slowly until a free flow of blood returns. Monitor the depth of needle insertion. Although the tip of the needle may not be visualized, the depth of the vessel is shown on the ultrasound monitor and should guide the depth of needle placement.

●Remove the transducer and complete cannulation in standard fashion as described below (table 2).

Access techniques — Palpation of the common femoral artery pulsation aids in anatomic localization of the vein (with or without ultrasound). The target venipuncture site is just inferior to the inguinal ligament, where the common femoral vein lies superficial and medial to the artery. Compression should be minimized or released prior to attempted venipuncture. Cooperative patients can also be asked to hum or perform a Valsalva maneuver to augment venous diameter.

The femoral vein is cannulated using the standard introducer needle with or without the aid of a seeker (or finder) needle, an angiocatheter catheter-over-needle assembly, or a micropuncture kit (picture 4). The technique for each of these is described below. Insert the needle 1 to 2 cm inferior to the inguinal ligament and just medial to the femoral artery.

In general, the needle should be introduced at a 20 to 30° angle to the skin. The vessel is normally reached within 2 to 4 cm but may be deeper in patients with edema or with obesity. If unsuccessful, perform systematic needle passes, working medial to lateral (while maintaining continuous negative pressure) until the common femoral vein is located. Take care not to push the needle into the periosteum of the pubic tubercle medially, as a tissue or bone plug can occlude the lumen of the needle.

Isolated arterial needle puncture is one of the most common complications of venous access but is typically uneventful if recognized [17]. Confirmation that the needle or angiocatheter is in the vein is essential prior to dilating the subcutaneous tissue and vein. (See 'Venous confirmation' below.)

There is a learning curve for central venous access procedures [18]. Experienced operators enjoy greater success rates with fewer complications. Among both experienced and inexperienced operators, an increased number of introducer needle passes correlates with increased complication rates, which are significantly higher after three unsuccessful passes [3]. If two attempts have been made, the needle should be completely removed the landmarks reassessed, a new access site chosen, or assistance obtained from a more experienced clinician [3,19,20].

Introducer needle — To access the femoral vein with the introducer needle:

●Insert the introducer needle (18 gauge) into the skin and apply continuous negative pressure by gently aspirating the plunger of the syringe. Some proceduralists find it helpful to have a small amount of saline in the syringe to minimize the formation of thrombus. Penetration into the vein will go unrecognized unless negative pressure is applied, but only a small amount of continuous negative pressure is needed (approximately 1 cc of a 10-cc syringe) during advancement of the needle.

●Traditionally, the bevel is directed anteriorly (bevel up) during insertion; however, orienting the bevel of the needle posteriorly (bevel down) may decrease the risk needle tip penetration of the posterior vein wall (ie, "past-pointing") [21].

●In many instances, the introducer needle compresses, but does not puncture, the compliant vein wall. The needle may ultimately compress the vessel and puncture the apposed anterior and posterior walls without entering the lumen. Failure to aspirate blood during needle advancement is common. As such, slowly withdraw the needle while maintaining continuous negative pressure and monitoring for blood aspiration.

●Always advance and withdraw the needle in the same vector. Lateral movement of an inserted needle can lacerate vessels and cause tissue injury should not be done. Prior to any redirection, the needle should be withdrawn to the skin surface.

●Anticipate that venous backflow into the introducer needle will be sudden, and steady your hand to avoid losing access when it occurs.

●Once access is achieved, stabilize the hub of the needle and carefully remove the syringe to avoid dislodging the introducer needle from the vessel.

●Limit open hub exposure and cover the hub of the needle between manipulations to avoid air entrainment. Coordinate open hub exposure with the patient's exhalation or consider encouraging the patient to hum or perform Valsalva maneuvers to augment central venous pressure [1,22].

Micropuncture needle — A 3.5 cm small-caliber (21- to 22-gauge) exploratory seeker needle, or micropuncture kit (picture 4), can be useful for initially locating the femoral vein. This technique minimizes injury in the event of inadvertent arterial puncture [19,23].

To use a seeker needle to aid introducer needle placement:

●As described above for large-bore needle access, insert the seeker needle while applying negative suction on the plunger of the syringe; more suction will be required (approximately 2 to 3 cc of a 10-cc syringe). Advance the needle as previously described. Steady, unimpeded blood return confirms intraluminal venous placement.

●Once the needle enters the femoral vein, withdraw the seeker needle, noting the angle and depth needed to reach the vein. Alternatively, remove the syringe, leaving the needle in place to anchor the vessel and provide a guide for venous access by the introducer needle. While applying negative pressure to the syringe, advance the introducer needle in the same vector, or alongside the preceding finder needle, into the vein.

Angiocatheter — An angiocatheter, which consists of an 18-gauge plastic catheter mounted on a 20-gauge needle, can also be used for initial femoral access. The needle tip is exposed and extends 2 mm distal to the catheter tip. The angiocatheter (not the needle) accommodates a standard 0.035" guidewire.

To use an angiocatheter for femoral venous access:

●Attach the catheter-over-needle unit to the syringe and advance it into the target vessel as described above.

●Once blood is aspirated, advance the needle another 2 to 3 mm to ensure intraluminal positioning of the tip of the catheter, then advance the catheter over the needle and into the vessel.

Venous confirmation — Confirmation of venous puncture and instrumentation is important to avoid inadvertent arterial injury. Ultrasound observation of needle tip entry into the vein is recommended but is sometimes difficult. As such, a second ultrasound verification step of guidewire placement within the vein following guidewire insertion is recommended prior to skin incision or tract dilation.

Steady flow of dark blood into the syringe should be recognized with venous cannulation. Bright red and high-pressure pulsatile bleeding are important but imperfect clues to arterial puncture [24]. Importantly, the absence of these signs is not perfectly reliable to exclude inadvertent arterial puncture. Dark, nonpulsatile backflow of blood may be seen with arterial puncture in the face of oxygen desaturation, hypotension, or needle malposition. If there is any doubt, the needle's location can be confirmed by pressure transduction. As an alternative, a blood gas can be drawn from the accessed venous site and compared with an arterial sample; however, blood gas analysis is more time-consuming.

To transduce the blood pressure:

●Attach the needle directly to the pressure tubing system.

●Alternatively, replace the needle over a guidewire with a 6-cm, 18-gauge single-lumen transduction catheter. Connect the transduction catheter to a pressure line and transducer and evaluate the pressure and waveform tracings on the monitor. Typical venous waveforms should be seen.

●If a pressure transduction system is not available, attach a short length of saline-filled intravenous tubing to the needle or catheter and extend it vertically to measure the pressure, which should be <15 cm in height, and demonstrate respiratory variation.

In addition to blood pressure transduction, echocardiography of saline flushed through the catheter can reportedly confirm intravenous access (ie, the FLUSH test). Using this technique, agitated saline is infused through the line while imaging the heart through a subxiphoid window. If atrial opacification can be demonstrated, this confirms venous access [25].

Inadvertent dilation and cannulation of the femoral artery with a standard catheter (less than 7.5 Fr) poses a more significant risk, but hemostasis is typically achieved with direct pressure after catheter removal. In contrast, large-bore catheters such as vascular sheath introducers or dialysis catheters may be associated with bleeding or vascular complications such as arterial thrombosis and embolization. If arterial catheterization with a large-bore catheter is confirmed, the catheter should be left in place to obtain vascular specialist consultation. This should also be considered in patients with standard catheters inadvertently placed into the femoral artery of coagulopathic patients.

CATHETER PLACEMENT — Most catheters and other central venous devices are placed using the Seldinger method, which refers to the use of a guidewire placed into a vessel to provide a conduit for intravascular device placement [7]. Seldinger first described the guidewire technique for arterial cannulation in 1953, and it was subsequently adopted for venous access procedures [7].

Guidewire handling — Once the femoral vein has been successfully accessed, a guidewire is advanced through the needle or angiocatheter.

Multiple types of wires are available to assist with venous access procedures. The most commonly used wire for initial venous access is a flexible J-tip guidewire, favored because it negotiates curvatures and avoids vessel trauma during passage (picture 5). Longer guidewires are used to place inferior vena cava filters and other venous devices (eg, stents), and, at times, more specialized wires (eg, hydrophilic) may be needed.

The guidewire should always pass smoothly and easily thorough the needle, dilator, or catheter without resistance. Methods to address resistance to guidewire advancement or withdrawal are discussed below.

To place the guidewire:

●Position the tapered plastic introducer to straighten the distal J-tip (picture 6). The orientation of the bevel tip of the introducer needle and the J-tip of the wire can help facilitate the direction of wire placement.

●Maintain the residual length of guidewire (50-cm standard length) under constant manual control to maintain sterility and avoid its loss off the operating field.

●Advance the guidewire only as far as needed to allow passage of the catheter over the wire.

●Never forcefully advance the guidewire, as this can kink and permanently deform the wire and risk vessel injury. The guidewire should always pass smoothly and easily through the needle, dilator, or catheter without resistance. Resistance to guidewire passage can be due to needle dislodgement, compression of the guidewire against the vessel wall, or anatomic obstruction. Rotating the needle and/or guidewire to reorient the bevel or J-tip may relieve impingement of the guidewire on the posterior vessel wall.

●If resistance persists, remove the guidewire and aspirate blood to confirm intraluminal needle position. Reducing the angle of the needle relative to the skin and target vessel may facilitate guidewire passage. Once the guidewire is advanced into proper position, hold it firmly in place and remove the needle.

●Resistance during guidewire withdrawal through the needle may indicate entrapment, typically due to guidewire kinking. A guidewire that resists removal should never be forcibly withdrawn through the needle because the wire can be sheared off by the needle, allowing the distal wire to embolize [26]. Simultaneous removal of the needle and indwelling wire avoids this mishap. Continued resistance during guidewire extraction warrants diagnostic radiography to evaluate the wire appearance and position.

Tract dilation — Central venous catheters are substantially larger caliber than the needle and guidewire used for venous access. Dilation of the subcutaneous tissue tract is required for catheter insertion and is accomplished by threading a single stiff tapered dilator or series of dilators over the wire to expand the subcutaneous tissue and vein. The skin and fascia catheter tract should be dilated carefully with gentle pressure. Only the soft tissue and vein wall need to be dilated. Overzealous efforts and guidewire kinking (especially with stiff dilators) risk traumatic vein injury.

To place the dilator:

●Once the guidewire is in place, make a controlled 3-mm stab incision at the skin entry site with a #11 blade.

●Thread the stiff tapered dilator over the wire, making certain the guidewire does not advance and is not pulled out at the skin exit site. The guidewire and dilator should never be advanced as a single unit, to avoid venous injury. The wire should serve as an immobile monorail over which the dilator (or catheter) is passed. Redundant tissue at the femoral site may require slight caudad skin traction to avoid kinking the wire during dilator advancement.

●Hold the wire just above the dilator hub, grasp the dilator just above its tip, and push it over the guidewire with a firm corkscrew motion (picture 7). Mild resistance is normal. Excessive resistance may represent an inadequate skin incision, a malpositioned guidewire, or guidewire or dilator deformation. Kinking of the guidewire against the dilator is associated with vessel trauma and puncture [27].

●Advance the dilator only to the anticipated depth of the femoral vein, not the entire length of the dilator. Withdraw the dilator while maintaining the guidewire position within the vessel. Apply direct pressure to the exit site to maintain hemostasis prior to catheter insertion.

●Steady caudad traction on the adjacent skin and tissue during dilatation helps prevent wire kinking between tissue layers. Rotating the dilator during advancement also facilitates tract dilatation (round dilators only). If resistance is met, it may be related to a kink in the wire, which can be remedied by advancing the wire deeper or withdrawing the kink into the dilator. Overzealous efforts and guidewire kinking (especially with stiff dilators) risk traumatic vein injury.

Many indwelling tunneled femoral catheters are placed through a peel-away sheath. To place these devices, a dilator-sheath combination is placed over the wire after the tract has been dilated. The dilator and wire are removed, and the catheter is placed through the sheath. Once the catheter is in place, the sheath is peeled away from the catheter and discarded. The dilator-sheath combination for large-bore tunneled catheters is stiff, and placement is facilitated with fluoroscopy, which allows imaging of the tip of the dilator and sheath, ensuring that it is placed no further into the vein than is necessary. (See 'Equipment' above.)

Positioning the catheter — After the subcutaneous tissues and vein have been dilated, the catheter is placed over the wire and positioned (picture 8).

To place and position the catheter:

●Thread the guidewire back through the end-hole of the catheter until it emerges from the distal port, and advance the catheter over the stabilized wire into the vessel (picture 9).

●Always maintain contact with the proximal guidewire as it exits the catheter hub during catheter advancement into the vein.

●Resistance to catheter advancement can be overcome by simultaneously advancing the catheter and wire together, but only for a short distance; otherwise, vein laceration can result. Withdrawal of the catheter and redilation of the tract is preferred.

●Completely remove the guidewire from the catheter hub following full catheter insertion. Retained intravascular guidewires during central venous access procedures often stem from forgetting this last removal step. Verbalizing guidewire removal is a common training step to prevent forgetting this critical step. Place the guidewire onto the sterile field for reuse or troubleshooting if needed.

Femoral venous catheters should be placed between 15 and 30 cm deep for correct positioning of the tip of the catheter in the inferior vena cava, but the depth depends upon the size of the patient. For hemodialysis catheters, flow rate through the catheter is the most important factor. Good flow rates can often be achieved with a femoral catheter tip that resides in the common iliac vein. Long, standard, 24 cm, nontunneled hemodialysis catheters will extend to that level from the femoral position of most patients and are recommended over shorter catheters to improve dialysis flow rates [8,9]. However, when placing tunneled femoral catheters for longer-term use (eg, Permacath), flow rates are often better maintained with catheters extending more centrally into the inferior vena cava. Longer catheters (up to 45 cm) are available for this purpose.

Catheter flushing and fixation — Once the catheter is in place, the proper function of the catheter should be confirmed by aspirating blood and subsequently flushing each port with saline (picture 1) [19,28]. The catheter should then be sutured into place.

The catheter should then be secured using 2-0 or 3-0 nylon or silk sutures (picture 10). If more than 2 cm of catheter remains exposed, it should be sutured to the skin or anchored with an additional catheter box clamp that is included in the catheter kit. A transparent dressing should be placed over the catheter exit site to protect it from contamination.

CONFIRMATION OF FEMORAL CATHETER POSITION — Unlike subclavian and jugular venous catheters, femoral venous catheters (nontunneled and tunneled) can be used immediately. Radiographic confirmation is not required if the catheter is operating properly. A postprocedure abdominal film can be performed to confirm the catheter course and tip position if the catheter is not functioning properly. Although it may be acceptable to have the catheter tip residing in the iliac vein for short-term use, the distal tip of femoral catheters should generally be located above the confluence of the iliac veins. (See "Central venous access in adults: General principles", section on 'Confirming catheter tip position'.)

In neonates and pediatric patients, ultrasound can be used to assist in gaining venous access as well as evaluating catheter tip position in the inferior vena cava [29]. This obviates need for fluoroscopy in a radiosensitive population and facilitates bedside catheter insertion. (See "Basic principles of ultrasound-guided venous access" and "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies".)

If a femoral catheter tip is positioned too proximally (eg, into a renal vein), it can be repositioned at the bedside using sterile technique. The sutures are removed and the catheter withdrawn and resutured into place. If a catheter is not in far enough or is misplaced into the contralateral iliac vein, it should be replaced over a guidewire under sterile conditions when convenient. Although this placement may not be deemed as ideal, the catheter can remain in the contralateral iliac vein for short-term use if the catheter is functioning well. It is important to remember that the portion of a catheter left out of the body is unsterile and should never be advanced into the patient, not even if it is under a sterile dressing.

CATHETER MANAGEMENT — The management of central catheters is discussed elsewhere. (See "Routine care and maintenance of intravenous devices".)

COMPLICATIONS — The complications associated with femoral venous access are discussed separately. (See "Central venous catheters: Overview of complications and prevention in adults".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Venous access".)

SUMMARY AND RECOMMENDATIONS

●Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling. Although femoral site cannulation is often recommended as a secondary site due to higher rates of delayed complications, the femoral veins remain a dependable venous access site. (See 'Introduction' above.)

●Following needle puncture, jugular catheters are placed using an orderly sequence of steps incorporating the modified Seldinger technique. (See 'General preparation' above.)

●For femoral venous cannulation, the patient should be positioned supine with the target leg abducted and externally rotated. Elevation of the buttock may facilitate exposure in some patients. Palpation of the common femoral artery pulsation aids in anatomic localization of the vein (with or without ultrasound). The target venipuncture site is just inferior to the inguinal ligament, where the common femoral vein lies superficial and medial to the artery. (See 'Positioning' above.)

●When equipment and expertise are available, we recommend children and adults undergoing femoral line placement should have the procedure guided by ultrasonography rather than using landmark techniques alone.

●Femoral artery needle puncture during attempted femoral vein localization is not uncommon and can be managed by withdrawing the needle and applying pressure over the site for 5 to 10 minutes, after which venous access can be reattempted. (See 'Venous confirmation' above.)

●Functioning femoral catheters do not require radiographic confirmation and can be used immediately following insertion. An abdominal film can be performed to confirm the catheter course and tip position if there is catheter malfunction. (See 'Confirmation of femoral catheter position' above.)