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Correspondence  |   July 2007
Ultrasound-guided “Low Approach” Femoral Vein Catheterization in Critical Care Patients Results in High Incidence of Deep Vein Thrombosis
Author Notes
  • Support was provided solely from institutional and/or departmental sources.
    Support was provided solely from institutional and/or departmental sources.×
    (Accepted for publication February 22, 2007.)
    (Accepted for publication February 22, 2007.)×
Article Information
Correspondence
Correspondence   |   July 2007
Ultrasound-guided “Low Approach” Femoral Vein Catheterization in Critical Care Patients Results in High Incidence of Deep Vein Thrombosis
Anesthesiology 7 2007, Vol.107, 181-182. doi:10.1097/01.anes.0000268280.02529.88
Anesthesiology 7 2007, Vol.107, 181-182. doi:10.1097/01.anes.0000268280.02529.88
To the Editor:—
Central venous access has traditionally been performed using puncture of a central vein, passing the needle along the anticipated line of the relevant vein using surface anatomical landmarks and by knowing the expected anatomical relation of the vein to its palpable, companion artery.1 ,2  If the surface landmark technique is not helpful, ultrasonic devices are widely used to cannulate central veins. Furthermore, reports have advocated that real-time ultrasound-guided placement of central venous catheter can be achieved quickly with low failure and complication rates in critical care patients.3 
The low femoral approach for catheterization of the femoral vein 10–15 cm below the inguinal ligament has been used for renal therapy in the intensive care unit.4  At this point, the companion artery is not palpable, and the anatomical landmarks guiding location of the femoral vein are also absent. Therefore, when performing this technique, the use of ultrasound guidance is considered indispensable. Finally, there are no extensive data indicating whether the application of the low femoral approach may result in a lower incidence the rate of central venous catheter–associated infection and/or thrombosis as compared with the classic method of catheterization of the femoral vein, which is performed 2 cm below the inguinal ligament. Therefore, we examined the above hypothesis in a series of critical care patients.
Institutional review board approval for the investigation was obtained by the intensive care unit department of the General State Hospital and by Athens University School of Medicine, Athens, Greece. We were planning to recruit 100 patients in each group of patients over a period of 3 yr. All patients recruited in the study were admitted for trauma not involving the lower extremities and were catheterized using the same technique as previously described.5  Patients were randomly assigned on a one-to-one ratio and stratified with regard to age, sex, and body mass index (by means of a computer table).5  Family members provided written, informed consent for all patients. Patients were excluded from the study if they had undergone a femoral catheterization in the past; if there was a local or systemic infection, recent surgery, or hematoma in the groin area; if there was ultrasonographic and clinical evidence of deep vein thrombosis (DVT); or if there was a known anatomic abnormality, a known hypercoagulable state, or history of congestive heart failure.
Forty patients (aged 40.3 ± 10.4 yr; body mass index, 22 ± 4.1 kg/m2; 18 female) underwent with the classic approach, and 40 patients (aged 41 ± 11.2 yr; body mass index, 22.5 ± 5 kg/m2; 16 female; all P nonsignificant) were catheterized by the low femoral approach (10–15 cm below the inguinal ligament). Catheters were placed in both positions with the aid of ultrasound. All patients were receiving prophylactic treatment with low-molecular-weight heparin. Visualization of thrombus formation, noncompressibility of the vein, no spontaneous Doppler flow, and lack of augmentation response were used as diagnostic criteria of DVT. Central venous catheter–associated bloodstream infections were defined as only those bloodstream infections for which other sources were excluded by careful examination of the patient record, and where a culture of the catheter tip demonstrated substantial colonies of an organism identical to those found in the bloodstream.5  The mean observational period was 40 ± 15 days. All patients were monitored every 48 h after the placement of the catheter for identification of a possible clot formation, and at the same time intervals, surveillance cultures were undertaken.
No mechanical complications were observed in the study population. There were no significant differences in the incidence of central venous catheter–associated bloodstream infections between the two groups (5 patients [12.5%] in the classic group and 6 patients [15%] in the low femoral group; P < 0.08). However, the incidence of DVT was significantly higher in the low femoral group compared with the classic group (13 patients [32.5%] vs. 4 patients [10%], respectively; P < 0.001). In 9 of the 13 patients of the low femoral group and in 1 of 4 patients of the classic group, the thrombus was located around the catheter and was detectable after 9 ± 4.5 days of insertion (fig. 1).
Fig. 1.
Visualization of catheter-associated thrombus in a patient catheterized by the low femoral approach.
Visualization of catheter-associated thrombus in a patient catheterized by the low femoral approach.
Fig. 1.
Visualization of catheter-associated thrombus in a patient catheterized by the low femoral approach.
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The current study was randomized but not blinded. The discontinuation criteria of this study were increased incidence of mechanical complications and/or catheter-associated DVT and/or infection. The high rate of thrombosis observed in the low femoral group of patients was alarming; hence the monitoring board, comprised of intensive care unit physicians, and the institutional review board have decided to discontinue the trial. The high incidence of DVT may be due to the fact that the diameter of the femoral vein catheterized just before its bifurcation by the low femoral approach was rather small, hence enabling the formation of thrombus around the catheter. We conclude that the low femoral approach increases the risk of DVT over the classic approach in critical care patients.
Dimitrios Karakitsos, M.D. Theodosios Saranteas, M.D., D.D.S., B.Sc., Ph.D.* Alexandros P. Patrianakos, M.D. Nicolaos Labropoulos, M.D., Ph.D. Andreas Karabinis, M.D., Ph.D. *General State Hospital of Athens, Athens, Greece. saranteas@ath.forthnet.gr
References
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Karakitsos, D, Labropoulos, N, De Groot, E, Patrianakos, AP, Kouraklis, G, Poularas, J, Samonis, G, Tsoutsos, DA, Konstadoulakis, MM, Karabinis, AReal-time ultrasound guided catheterization of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients.. Crit Care. (2006). ; 17:10:R12
Fig. 1.
Visualization of catheter-associated thrombus in a patient catheterized by the low femoral approach.
Visualization of catheter-associated thrombus in a patient catheterized by the low femoral approach.
Fig. 1.
Visualization of catheter-associated thrombus in a patient catheterized by the low femoral approach.
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