Femoral venous access

When embolotherapy is indicated, the patient is transferred to an angiographic suite. Intensive care physicians should be present during the procedure. Right femoral artery access is obtained, and a 4-or 5-F sheath is inserted. Additionally, left femoral venous access may be obtained to be used by the intensive care physician if no other central access is available for supportive therapy. 

Blood collection from the femoral artery is mentioned by Davis et al. (1994) after surgically preparing vascular access ports to the femoral artery. Using dogs with surgically instrumented indwelling venous access ports into the femoral vein and using a 6 min infusion instead of a intravenous bolus injection is mentioned by... 

C. Secure venous access. Antecubital or forearm veins are usually easy to cannulate. Alternative sites include femoral, subclavian, internal jugular, or other central veins. Access to central veins is technically more difficult but allows measurement of central venous pressure and placement of a pacemaker or pulmonary artery lines. 

Leads are usually removed via the implant vein, which is the venous access by which the lead was inserted. However, sometimes, alternative venous access is required from a nonimplant vein. Examples of alternative approaches to subclavian vein include femoral and jugular veins. Relative contraindications for transvenous lead removal [2] are addressed in this chapter to emphasize that the unavailability of the necessary equipment represents a contraindication to transvenous lead removal ... 

After venous access, some consideration should be given to the sequence of lead placement. Some operators prefer to place the RV electrode first for emergency RV pacing, should heart block ensue because the heart failure patients commonly have a left bundle branch block and any trauma to the conduction system or right bundle may result in complete heart block. Other operators choose to place the coronary sinus lead first and, if necessary, depend on heart rate support via a temporary transvenous pacemaker placed via the femoral vein. The issue of failure speaks for placing the coronary sinus lead first. Should the procedure fail with unsuccessful left-sided left ventricular lead placement and the patient has already received right-sided electrodes, a pacing system may be left without an indication unless a future second attempt is considered. As more and more systems are placed for a primary prevention indication like MADIT II, this has become less problematic (153). 

Venous access can be obtained by several approaches. The internal jugular veins, subclavian veins, and femoral veins are aU potential sites for introduction of the pacing catheter into the right heart (Table 7.2). The median basilic veins and basilic veins can also be used, but these sites are associated with a very high incidence of catheter dislodgment (because of arm motion) and are rarely, if ever, used today. 

Before obtaining venous access, the existence of a bleeding diathesis or coagulopathy should be excluded or corrected if possible. If this is not possible, the femoral vein should be considered as the initial access site... 

Once venous access is obtained, the pacing catheter must be placed into the appropriate intracardiac position to begin pacing. A variety of leads that range from 3 to 6Fr in diameter can be nsed for transvenous temporary pacing. Balloon-tipped flotation electrode catheters nse vascular and intracardiac blood flow to direct them into the right ventricle. Balloon-tipped pacing catheters are very pliable and are also available with preformed curvature to facilitate placement from the femoral vein. Traditional temporary electrode catheters are relatively stiff, and must be placed in the ventricle with the aid of fluoroscopy. Traditional electrode catheters come in a variety of shapes... 

The femoral vein is used in a similar manner as any other more conventional access site. The tunnel or pocket is created on the lower abdominal wall or even the lower chest wall. It is important to widely separate the catheter exit site or pocket from the venous access site to minimize infectious complications. 

Many different types of venous-access devices are available. Peripherally inserted central venous catheters (PICCs), which can be made of PU or silicone, are inserted into a vein in the arm rather than in the neck or chest. Nontunneled CVCs are shortterm catheters, made of PU or silicone as well, inserted into the internal jugular, subclavian, or femoral vein. Tunneled CVCs are long-term catheters implanted surgically under the skin. One end of the catheter remains outside the skin and the exit site is typically located in the chest. Passing the catheter under the skin helps to reduce the infection risk and provides stability. Implantable ports are similar to tunneled catheters but are left completely under the skin. They consist in small devices, made of plastic or titanium, inserted beneath the skin and connected to a catheter allowing vascular access. Under the skin, the port has a septum through which drugs can be injected and blood samples can be withdrawn. 

In patients with CKD, preservation of the integrity of peripheral and central veins is of vital importance for future hemodialysis access. Avoid i.v. infusion or vein puncture in the forearm and upper arm veins at both arms whenever possible. Insertion of venous access devices carries the risk to injure the veins and thereby incite phlebitis, sclerosis, stenosis or thrombosis and has to be avoided. Whenever a central venous catheter is needed, catheterization of the internal jugular or femoral vein is always preferred. Use of subclavian vein should be... 

The anatomic location for temporary central venous catheter (CVC) insertion and placement can be dictated by certain patient or disease restrictions, but the most common sites are the internal jugular vein (neck), the femoral vein (groin), and the subclavian position (upper chest). The internal jugular approach is the first choice for placement of a hemodialysis CVC, while femoral placement is favored when rapid insertion is essential (Canaud et al., 2000). Subclavian vein access has fallen from favor because of a higher incidence of thrombosis and stenosis associated with this site, which can ultimately prevent use of the veins in the downstream vascular tree for high-flow applications such as dialysis (Cimochowski et al., 1990 Schillinger et al., 1991). 

In certain sitnations the internal jugular or subclavian veins may be inaccessible or the patient may have uncorrectable thrombocytopenia or coagulopathy, which necessitates access to the central venous system by the femoral vein. When using this approach for temporary pacing, fluoroscopy is required for pacing catheter placement. In addition to the need for fluoroscopy, other disadvantages include patient comfort (because the leg cannot be bent at the hip), increased risk of infection, and poor catheter stability. 

In the presence of rapid venous drainage or massive venous spaces, placement of coils can be useful to retain sclerosing agent and avoid pulmonary embolus, particularly in a venous malformations close to normal veins. Coils can be delivered directly through the access needle into the venous spaces or via the femoral or jugular vein (Fig. 2. lOa-e). For limb superficial venous malformations, a peripheral intravenous catheter can be useful to perform a phlebography during sclerotherapy for assess-... 

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