• 
• 

Three Part Question

In [patients requiring central venous pressure monitoring] does the insertion of [a femoral central line as apposed to an internal jugular or subclavian line] increase the rate of [thrombotic complications]?

Clinical Scenario

You are in the emergency department attending to a 68 year old gentleman who was found in his car which had left the road and hit a tree. On arrival his GCS was 6 and he had 2 fractured clavicles and an open fracture of the left humerus. His BP is 90/50 and his pulse is 110 and after stabilisation you call an anaesthetist to intubate him, with cervical collar in situ. While he is doing this, you find multiple medications for heart failure in his pockets and the radiographer brings you a large packet of his old films including several showing pulmonary oedema over the last few days. There is nothing acute on his ECG and only cerebral oedema is seen on the head CT. You can see that his fluid balance will be very difficult to manage over the next few days. You elect to insert a femoral central line but wonder if there will be any additional risks to placing this into the femoral vein rather than the currently inaccessible cervical region.

Search Strategy

Medline 1966-07/04 using the OVID interface.
[(exp femoral vein OR femoral vein.mp) AND (exp catheterisation, central venous OR exp Catheterisation OR catheterisation.mp) AND (exp thrombosis OR thrombosis.mp OR exp venous thrombosis)] AND maximally sensitive RCT filter

Search Outcome

Altogether 90 papers were found of which 7 were relevant. A further paper was found by cross-referencing. These papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kanter RK et al, 1986, USA,	Phase 1: 3 year surveillance in paediatric ICU of 161 catheters (49 femoral) (1/3rd of children under 10kg) Phase 2: 29 paediatric patients needing central line had femoral line 77% had Ultrasound evaluation for thrombus	Cohort study	Phase 1 complications	Femoral line: 6.1% complication rate incl. 3 leg swellings Neck sites: 4.5% complication rate, incl. 2 arm swellings	Poor gold standard for excluding thrombus as no children received ultrasound scanning or other imaging to look for thrombus, even if their leg swelled Also 14% arterial puncture rate
			Phase 2 complications	Leg swelling in 4 patients and 1 thrombus around catheter at autopsy (11% adverse incident rate)
Shefler A et al, 1995, Australia	56 femoral lines in 54 children in a general pediatric ICU. Mean age 36mths range 0-192 mths All patients had USS examination within 3 days of insertion and repeated every 2-4 days	Prospective cohort study	Thrombotic complications	IVC thrombosis was found in 6/56 children (10.6%). All 6 were found on, or after 8 days of insertion. Thrombi found on day: 8, 8, 10, 20 and 20. Only 1 patient showed clinical signs	Small uncontrolled cohort No attempt to look at USS of lower limb deep veins May not be applicable to adult or older child groups
Trottier SJ et al, 1995,	45 patients in a medical and surgical ICU Randomised to upper or lower central line placement Ultrasonography performed before insertion, after removal and 7 days after removal	PRCT	Thrombotic complications	Upper access sites: 0/21 positive ultrasound findings Femoral access sites: 6/25 had DVT clinically and an additional 7/25 had USS findings of thrombosis	The USS examination did not look at the upper extremity deep veins There were 7 more triple lumen catheters inserted into the femoral vein than single lumen catheters, compared to upper access sites
Durbec O et al, 1997, France	80 consecutive patients undergoing femoral central line in a single adult ICU	Observational cohort study	Thrombotic complications	No clinical signs of DVTs or PEs seen, but on phlebography 34% of patients had DVT and 25% popliteal thrombosis	No power study performed Uncontrolled study
Durbec O et al, 1997, France	61 ICU patients undergoing either femoral venous catheterisation (31) or internal jugular (10) or axillary vein (21) cannulation Bilateral leg phlebography performed on removal	PRCT	Thrombotic complications	No patient had clinical signs of a DVT or PE	Axillary vein cannulation is an atypical site to use as a control group No power calculations, underpowered study
			Phlebography	Fibrin sleeve seen in 23% of femoral group and non in SVC group 2. Femoral vein thromboses seen in Femoral group and 1 femoral vein thrombosis in the SVC cannula group
Timsit JF et al, 1999, France	336 patients in 3 French Intensive Care Units Randomly assigned to tunneled or non-tunneled femoral venous catheter 10cm tunnel was used	PRCT	Time for insertion	15 mins for non-tunneled line and 25 mins for tunnelled line	92% were ventilated
			Thrombotic complications	7 DVTs 9 insertion failures 25 arterial punctures
Joynt GM et al, 2000, Hong Kong	140 patients in an Intensive Care Unit, all receiving a femoral line Duplex Ultrasound performed prior to insertion, 12hrs after insertion and then daily until removal	Cohort study	Thrombotic complications	12 iliofemoral DVTs found in cannulated leg 2 found in uncannulated leg Positive findings were not related to coagulation status, attempts at insertion, duration of catheterisation, or heparin-bonded line use	No control group to compare the types of complication found with subclavian line, e.g. pneumothorax, but otherwise a well conducted study
Merrer J et al, 2001, France	289 adult patients in 8 French Intensive Care Units receiving first central line Randomly assigned to femoral insertion (N=145) or subclavian insertion (N=144)	PRCT	Thrombotic complications	USS detected Femoral 21.5% Subclavian 1.9%, P<0.01 Major thrombosis: femoral 6% subclavian 0%	Thrombotic complications only assessed in 76% of patients, (but reasons for all of these were accounted for) Otherwise well conducted study Number needed to treat

Comment(s)

All studies found evidence of thrombosis after femoral central line insertion. Rates ranged from a 2% rate of DVTs seen clinically by Timsit et al in a study that did not specifically look for evidence of a DVT, to 21% detection of thrombus by USS by Merrer et al, a 34% rate of thrombus detection on phlebography by Durbec et al. Of note Joynt et al found an 8% rate of Iliofemoral DVTS, but 2 DVTs were also seen in contralateral, uncannulated legs. All studies detect high rates of lower limb thromboses and therefore extreme caution should be used when deciding to insert a femoral central line. If a femoral line is deemed necessary attention should be paid to gaining access elsewhere at the earliest possible opportunity.

Clinical Bottom Line

Central lines inserted into the femoral vein have an unacceptably high rate of thrombotic complications and efforts to minimise the use of this route of access should be taken.

References

1. Kanter RK, Zimmerman JJ, Strauss RH, et al. Central venous catheter insertion by femoral vein: safety and effectiveness for the pediatric patient. Pediatrics 1986;77:842-7.
2. Shefler A, Gillis J, Lam A, et al. Inferior vena cava thrombosis as a complication of femoral vein catheterization. Arch Dis Child 1995;72(4):343-5.
3. Trottier SJ, Veremakis C, O'Brien J et al. Femoral Deep vein thrombosis associated with central venour catheterization : results from a prospective randomized trial. Crit Care Med 1995;23(1):52-59.
4. Durbec O, Viviand X, Potie F, et al. A prospective evaluation of the use of femoral venous catheters in critically ill adults. Crit Care Med 1997;25:1986-9.
5. Durbec O, Viviand X, Potie F, et al. Lower extremity deep vein thrombosis: a prospective, randomized, controlled trial in comatose or sedated patients undergoing femoral vein catheterization. Crit Care Med 1997;25:1982-5.
6. Timsit JF, Bruneel F, Cheval C, et al. Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial. Ann Intern Med 1999;130:729-35.
7. Joynt GM, Kew J, Gomersall CD, et al. Deep venous thrombosis caused by femoral venous catheters in critically ill adult patients. Chest 2000;117:178-83.
8. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286(6):700-7.