Femoral Arterial Access and Complications
Femoral nerve – Innervates the anterior compartment of the thigh, and provides sensory The femoral artery, vein and canal are contained within a fascial Prevascular femoral hernia and its relation with inferior epigastric. ATOTW – Ultrasound Guided Femoral Nerve Block, 15/04/ Page 1 of 10 Medially is the femoral artery and vein enclosed in their femoral sheath . lateral femoral circumflex (L) artery in relation to femoral nerve. . Ultrasound guidance has the potential to make the block more reliable and safer. Anatomical relationship of the femoral nerve, artery, and vein. preferably by using an electrical nerve stimulator or ultrasound for guidance.
Cloquet's node also known as Rosenmuller's node also lies in this canal.
It receives lymphatic drainage from superficial inguinal lymph nodes, lymphatic drainage from the glans penis or clitorisand from the deep lymphatics of the lower limb. Heavy bleeding in the leg can be stopped by applying pressure to points in the femoral triangle. Another clinical significance of the femoral triangle is that the femoral artery is positioned at the midinguinal point midpoint between the pubic symphysis and the anterior superior iliac spine ; medial to it lies the femoral vein.
Thus the femoral vein, once located, allows for femoral venipuncture. Femoral venopuncture is useful when there are no superficial veins that can be aspirated in a patient, in the case of collapsed veins in other parts of body e. The positive pulsation of the femoral artery signifies that the heart is beating and also blood is flowing to the lower extremity[ citation needed ]. It is also necessary to appreciate clinically that this is a case where the nerve is more lateral than the vein.
In most other cases the nerve relative to its associated artery and vein would be the deepest or more medial followed by the artery and then the vein. But in this case it is the opposite. This must be remembered when venous or arterial samples are required from the femoral vessels. The basins are separated by the fascia lata. For patients with palpable nodal disease, removal of the superficial and deep basins are recommended.
In a patient with a positive sentinel lymph node biopsy, generally only the superficial nodes are removed, unless Cloquet's node the most superior of the deep nodes is clinically positive. Start with a dermal bleb using a gauge needle to anesthetize the skin. Using a long gauge needle, anesthetize deeper tissue planes and on either side of the femoral artery.
Administer 10 to 20 cc of local anesthesia, good enough for patient comfort but not so excessive as to obscure pulsations.
Femoral vein - Wikipedia
Make a 2 to 4 mm nick parallel to the skin crease at the identified site of the femoral artery puncture. The nick can be enlarged and deepened using the tip of a small curved forceps.
The nick and tunnel approach may not be necessary for smaller size sheaths. The disadvantage of the nick and tunnel approach is the need for a repeat nick in case the nick was not performed at the site of the artery.
In addition, it may be preferable to perform the nick once the femoral artery has been entered with an gauge needle.
The Femoral Triangle
Care must be taken not to make the nick over a soft guidewire such as a hydrophilic wire to avoid the risk of cutting the wire. Avoid back wall puncture whenever possible. Enter the skin at a to degree angle so as to cannulate the artery 2 cm superior to the skin incision. Ensure pulsatile blood flow before wire advancement. If any resistance is encountered during wire advancement, advance under fluoroscopy. With sufficient length of wire in place, exchange the cannulation needle to a femoral arterial sheath.
Remove the dilator leaving behind the J-tipped guidewire and flush the side port of the sheath. Perform femoral angiography in the ipsilateral oblique view and preferably prior to the start of the procedure to identify the site of femoral artery cannulation and to assess for any complications perforation, dissection, etc. It may be a good practice to leave the J-tipped guidewire in the artery prior to femoral angiography. This will ensure that the tip of the femoral artery sheath is not buried into a plaque as injecting dye into it can lead to femoral artery dissection; also, this practice prevents inadvertent pulling out of the sheath during angiography.
A vascular ultrasound probe 5 to 10 Hz can be used to locate the CFA and arterial access obtained under direct ultrasound guidance. Add ultrasound gel on the vascular probe and cover the probe with a sterile sleeve. Add additional ultrasound gel over the sleeve.
First locate the bifurcation of the femoral artery. Once the bifurcation is identified, trace the artery proximally to identify the common femoral artery. Under direct ultrasound guidance advance the gauge needle. As the needle passes through the tissue planes, the indentation on the artery by the advancing needle can be identified on the ultrasound. Adjust the direction of the needle based on the position on the ultrasound and puncture the artery.
Some ultrasound probes have a needle guide that fixes the angle of entry of the needle to within the area of the ultrasound beam and thus aids in easy puncture.
Avoids cannulation at the bifurcation in arteries with a high bifurcation and reduces the chances of arteriovenous fistula by avoiding cannulation of the femoral vein at sites where the femoral vein is directly on top of the artery.
Additional time taken to set up the ultrasound and the need for a ultrasound probe and console. The probe is within the lumen of the needle. The needle is connected to a handheld Doppler monitor wrapped in a sterile sleeve where the Doppler sound is amplified so that the performing physician can hear the sound as the needle approaches the artery or the vein.
Advance the needle similar to that of the standard gauge needle while listening to the Doppler signal. When the needle approaches the artery, the Doppler signal becomes louder, assisting in femoral arterial cannulation. Once the needle enters the artery, ensure pulsatile blood flow and the rest of the procedure is as described above. In patients who are fully anticoagulated, it may be desirable to obtain femoral access using a smaller gauge needle to reduce the risk of access site complications.
The micropuncture needle is a gauge needle compared with a standard gauge needle. The micropuncture kit consists of a gauge stainless steel needle, a 0. Advance the micropuncture needle similar to the standard gauge needle. Once the artery is cannulated, ensure adequate blood flow but bearing in mind that the blood flow may not be as pulsatile as that with a standard gauge needle.
Insert and advance the 0.
- Femoral triangle
- Lower Limb Anatomy: The Femoral Triangle
- Femoral Arterial Access and Complications
Remove the micropuncture needle over the guidewire and exchange for the 4 Fr micropuncture sheath and dilator. Remove the dilator and the guidewire. Brisk pulsatile arterial flow should be noted at this stage. Never attempt to remove the 0. In patients with post iliofemoral bypass grafts, an alternate approach such as transradial approach or femoral approach via the nongrafted site should be considered.
However, a prior iliofemoral bypass graft in itself is not a contraindication for ipsilateral femoral access and access can be obtained safely using a micropuncture needle described above.
In morbidly obese patients, an alternate approach such as transradial approach should be considered. However, if the femoral approach is chosen, the needle should enter more vertically to avoid a high stick.
Use of micropuncture needle may be desirable. Complications and their management Femoral access site complications are perhaps the most common complications in patients undergoing coronary angiography and interventions.
Recognition and early treatment of these complications can prevent more serious complications and death. Femoral arteriovenous fistulae are abnormal communications between femoral artery and the femoral vein at the site of sheath insertion.
The risk factors for AV fistulae are: Low femoral puncture puncture of the profunda femoris vein that lies close to the superficial femoral arterymultiple punctures, through and through puncture of overlying vein, large sheath size, ineffective manual compression, female gender, anticoagulant and antifibrinolytic therapy, therapeutic procedures as opposed to diagnostic proceduresolder age, and arterial hypertension.
Patients can complain of abnormal sensation on the groin vibration like or fatigue due to shunting. Duplex ultrasound is the test of choice. Arteriography CT or angiography is rarely required. Small AV fistula needs only observation and serial ultrasound and the fistula usually closes by itself spontaneous thrombosis. For larger AV fistula and if patient is symptomatic, ultrasound guided compression for up to 1 hour is recommended.
Other treatment options include: Pseudoaneurysm occurs when there is communication between the artery and overlying hematoma such that the blood flows intermittently during systole and diastole into the hematoma sac. The risk factors for pseudoaneurysm are: Patients present with pain and swelling at the access site or may be asymptomatic. Physical exam reveals a pulsatile swelling with a bruit.
Retrograde dissection of the femoral artery occurs as a result of the needle or the guidewire entering the dissection plane at the time of femoral artery cannulation. In addition, dissection can occur during femoral angiography if the sheath is up against the wall of the femoral artery angiography with the guidewire in place will reduce the chance of this occurrence as described above.
Most dissections are discovered on femoral angiography and are usually asymptomatic.
Lower Limb Anatomy: The Femoral Triangle - Ponder Med
The dissection flap is held open by the antegrade flow of blood and rarely results in complete occlusion of the femoral artery. Most dissections are discovered on femoral angiography. Dissections resulting in femoral artery occlusion will result in ipsilateral lower leg pain with signs of arterial insufficiency 5 Ps described below. Most dissections without occlusion are usually asymptomatic and no definitive treatment is needed.
However, if the dissection is discovered on femoral angiography, it may be prudent to withdraw the sheath back and repeat femoral angiography using hand injection of contrast to ensure that the artery will not completely occlude upon sheath removal. In patients with femoral artery occlusion, contralateral access with attempted percutaneous or surgical approaches to femoral artery recanalization will be required. Acute ischemic limb is a surgical emergency and is described below.