Anatomy

The common femoral vein is predominantly a deep vein of the lower limb present in the femoral triangle where it lies superficial before entering the pelvis beneath the inguinal ligament to continue as an external iliac vein. The femoral triangle is formed in the inguinal-femoral area by the inguinal ligament superiorly, adductor longus medially, and sartorius muscle laterally. The neuromuscular bundle in the triangle consists of the femoral vein, artery, and nerve from medial to lateral (Fig. 2A). Whereas the femoral vein lies just medial to the artery within the femoral sheath, the nerve lies outside it. Distally in the limb, the femoral vein lies posterior to the artery, and an attempt to cannulate the vein usually results in an ardent arterial puncture. Hence one should avoid this low a venipuncture.

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Fig. 2 (A) Anatomy of femoral vein. (B) Surface markings of femoral vein.

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Fig. 2 (A) Anatomy of femoral vein. (B) Surface markings of femoral vein.

Surface Markings

The femoral artery lies at the midinguinal point (Fig. 2B) that corresponds to the central point of the imaginary line connecting the symphysis pubis and anterior superior iliac spine.1 The femoral vein lies approximately 1 and 0.5 cm medial to the femoral artery impulse in adults and children, respectively.2 The femoral vein is identified by localizing the maximal arterial pulsations just beneath the inguinal ligament and puncturing the skin 1 cm below and 0.5 cm medial to it. Some operators rely on the location of the inguinal skin crease to position the skin nicks, but the position of the skin crease itself can be misleading in obese patients. Localization of the skin nick can be done under fluoroscopic guidance, and the nick should overlie the inferior border of the femoral head.

Patient Preparation

• A wide skin preparation involving the anterior and medial surface of the proximal thigh with extension above the inguinal ligament is required.

• The hair in this area should be clipped or shaved, preferably the former.

• The proposed puncture site should be cleaned with alcohol and povidone-iodine or chlorhexidine swab. Chlorhexidine is preferred as the antimicrobial effect lasts longer, nearly 6 hours.

• The puncture site should be isolated with sterile drapes.

Procedure

Indications

Contraindications

• Absolute contraindications

  • ○ Venous injury at the level of femoral veins or proximal

  • ○ Known or suspected thrombosis of femoral or iliac veins on the proposed side of cannulation

  • ○ Ambulatory patient—the risk of catheter fracture and migration

• Relative contraindications

  • ○ Bleeding disorders

  • ○ Distorted anatomy of veins

  • ○ Previous long-term venous catheterization

  • ○ History of vasculitis

  • ○ Previous injection of sclerosis agents or radiation therapy (Tables. 1 2)

Advantages

• Gaining access in emergencies and patients in shock is relatively easier.

• The femoral area is relatively free of other monitoring devices and proves advantageous in a critically ill patient.

• The femoral access is preferable in a bedridden patient as it allows free movement of arms and necks without interrupting the access lines.

• Femoral access precludes the development of hemothorax/pneumothorax and is preferred to other vascular sites in patients with severe coagulopathy or respiratory failure.

Disadvantages

The femoral site is potentially contaminated because of its proximity to the perineal region. Catheter-related bloodstream infections (CRBSIs) were less with jugular and sub-clavian access than with femoral according to earlier studies. However, subsequent studies from 2008 to 2010 showed no difference among the three sites regarding CRBSIs.11

Anatomy

Internal jugular vein is not visible externally. It originates from the jugular foramen at the skull base as the continuation of the sigmoid sinus. It ends behind the sternoclavicular joint where it joins the subclavian vein. It runs along with the carotid artery and vagus nerve in the carotid sheath throughout its entire course. The IJV is initially posterior, then lateral, and finally anterolateral to the carotid during its course. At the level of the cricoids cartilage, it lies beneath the sternocleidomastoid muscle and emerges at the apex of the triangle formed by the sternal and clavicular heads of the muscle (Fig. 3).

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Fig. 3 Anatomy of internal jugular vein.

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Fig. 3 Anatomy of internal jugular vein.

The right IJV is preferable for cannulation over the left IJV due to the following reasons:

• It is larger in caliber.

• It is relatively straight while the left IJV takes right-angled turns before entering the right atrium; thus, it increases the chances of vessel rupture leading to hemothorax.

• The left IJV lies anterior to the thoracic duct. Thus right IJV is preferred to avoid any ductal injury.

• The dome of the right pleura is relatively lower, hence fewer chances of pneumothorax.

• Relative ease for a right-handed operator.

Surface Landmarks

The IJV runs from the earlobe to the medial clavicular border,12 between the sternal and clavicular heads of the sternocleidomastoid muscle. It is easier to cannulate the IJV below the level of cricoid cartilage as tributaries join in the upper neck. The common carotid artery travels adjacent the IJV and is a useful landmark to locate the IJV. There is a slight gap between the right IJV and carotid artery while the left IJV overlays the carotid artery.

The anterior, central, and posterior are three main approaches to cannulate the IJV. These approaches are named according to the relationship with the sternocleidomastoid muscle. The central approach is preferred.

Approaches

• Central—most common and preferred approach

• Anterior

• Posterior (Table 3)

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Fig. 4 (A) Central approach of IJV puncture. (B) Anterior approach to IJV puncture. (C) Posterior approach to IJV puncture.

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Fig. 4 (A) Central approach of IJV puncture. (B) Anterior approach to IJV puncture. (C) Posterior approach to IJV puncture.

Patient Preparation and Position

• A wide area including the skin and chest up to the nipples should be draped sterile.

• The patient should be in supine position; Trendelenburg's position with 10 to 15 degrees head down is preferred if tolerated to make the IJV prominent.

• The neutral position of the head is best to separate the IJV and carotid artery to avoid accidental arterial puncture.

• Some recommend turning the head slightly to the opposite side to make the heads of the sternocleidomastoid prominent. However, in this position, the vessels overlap and the IJV diminishes in diameter.

In a trial of 650 patients, assigned randomly to neutral versus turned (45 degrees) during ultrasound-guided cannulation of the IJV, technical success was 100% with no significant difference in complications between the two groups.

• Anesthetize the area with 10 mL of lidocaine aspirating and ensure that the IJV or carotid is not touched. A 25-mm needle is used for this purpose. The same needle attached to a 2- to 5-mL syringe can be used to localize the IJV.

Anatomical Landmark Technique

Indications

• TPI

• Venous access—fluid resuscitation, infusion of hypertonic solutions, temporary dialysis

• Venous access for pulmonary artery catheterization

• Device closure—post–myocardial infarction (MI) VSD cases

Contraindications

There are no absolute contraindications. Relative contraindications are:

• Mechanical problems in access of the neck-skin trauma, infection, scar, mass

• Coagulopathy

• Patient non-cooperation

Complications

• Infection

• Pneumothorax—when the apex of the lung is punctured

• Hemothorax—especially if a venopleural fistula is created

• Chylothorax occurs if the thoracic duct is injured

• Cerebrovascular accident (CVA)—when the carotid artery is punctured inadvertently due to interruption of blood supply to the brain or due to embolization

• Hematoma

• Airway compression—due to hematoma

• Air embolism—if the catheter lumen is left open to the air during insertion

• Arrhythmia—if the catheter tip irritates the right ventricle

• Thrombosis

Anatomy

The axillary vein courses medially to become the subclavian vein as it passes anteriorly to the first rib. The subclavian vein forms the brachiocephalic trunk after joining the internal jugular vein. After crossing the first rib, the vein lies posterior to the medial third of the clavicle at the change in curvature of the clavicle (Fig. 5). Deep to the vein is the anterior scalene muscle followed by the subclavian artery (Fig. 5). The thoracic duct joins the junction of the left internal jugular vein and left subclavian vein, which can get punctured while cannulating the left subclavian vein; hence, the right subclavian vein is preferred for central venous access. The subclavian artery lies posterior to the vein.

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Fig. 5 Anatomy of subclavian vessels.

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Fig. 5 Anatomy of subclavian vessels.

Approaches16

• Infraclavicular

• Supraclavicular (Table 4)

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Fig. 6 (A) Intraclavicle approach to subclavian vein puncture. (B) Supraclavicle approach to subclavian vein puncture.

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Fig. 6 (A) Intraclavicle approach to subclavian vein puncture. (B) Supraclavicle approach to subclavian vein puncture.

Indications

• Tembporary pacing

• Permanent pacemaker insertion

• Chemo port—to deliver chemotherapy drugs

Contraindications

Contraindications exist in coagulopathies and in patients receiving thrombolysis as the subclavian vein cannot be compressed.

Complications17

• Infection.

• Pneumothorax—when the lung is punctured. This is the most dreaded complication, and subclavian venous access should not be attempted if the facilities to manage this complication are not available.4

• Hemothorax—especially if a venopleural fistula is created.

• Chylothorax occurs if the thoracic duct is injured especially on the left side.

• Air embolism—if the catheter lumens are left open to the air during insertion.

• Arrhythmia—if the catheter tip irritates the right ventricle.

• Thrombosis.

• Brachial plexus injury.

Anatomy

The axillary vein is the continuation of the basilic vein. It begins at the lower end of the Teres major muscle and terminates beneath the clavicle at the outer border of the first rib where it continues as subclavian vein. It is accompanied by the axillary artery, which is slightly lateral and posterior to the vein. It is covered anteriorly by the pectoralis minor, major and clavipectoral fascia. The pectoralis major crosses the axillary vein anteriorly and divides it into three parts: proximal, posterior, and distal. As one moves laterally toward the rib cage, the axillary vein and artery are separated and further away from the rib cage. This anatomical site is suited for venous access, despite the relatively small caliber of the vein at the site. The depth of the vein and lack of obvious surface landmarks suggest that ultrasound should be used for access (Fig. 7).

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Fig. 7 Anatomy of axillary vein.

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Fig. 7 Anatomy of axillary vein.

Surface Landmarks

The clavicle, coracoid process, and deltopectoral grove are important landmarks for axillary vein localization. The coracoid process is the bony prominence palpated on the anterior should, and deltopectoral groove is the crease there formed by the lateral border of the pectoralis major muscle and medial border of the deltoid muscle. Axillary artery pulsations can be felt in the superior part of the deltopectoral groove, and the vein lies anterior and medial to it. The clavicle also helps in localizing the vein that lies in the infraclavicular space just before it rolls over the first rib.

Techniques

• Blind landmark technique: First suggested by Nickalls in 1987.19 It aims at the infraclavicular portion of the axillary vein.

  • ○ The needle is inserted three finger breadth below the coracoid process slightly lateral to the lateral border of pectoralis minor.

  • ○ The needle is directed toward a point below the medial end of the clavicle, that is, the palpable space between the clavicle and thorax.

  • ○ This corresponds to the junction of medial and lateral three-quarters of the clavicle. Successful cannulation was done in 96%. Belott described the same with slight modification.

  • ○ Advance needle 1 to 2 cm medial to the deltopectoral grove in a superior and medial direction parallel to the groove.

However, this method failed to gain widespread recognition due to anatomical reliability of the vein and its surface landmarks. Ultrasound or fluoroscopic guidance approach to axillary vein puncture is advocated.

• Fluoroscopy-guided low approach 20 : First rib guidance (Fig. 8). Fluoroscopy-guided lateral approach—via the rib cage margin (Fig. 8).

  • ○ First rib approach fluoroscopy guided: The axillary vein to be punctured at the juncture where the clavicle crosses the first rib. Needle is inserted still below, at 45 to 60 degrees to body surface along the greater curvature of the first rib, toward the root of the neck. One should not advance the needle beyond the medial border of the first rib. If the vein is entered, blood could be aspirated. If the bone is hit, withdraw and reorient the needle slightly anterior or posterior, that is, walking through the rib technique.

  • ○ Rib cage approach fluoroscopy guided: The axillary vein is punctured at the lateral edge of the rib cage at the confluence of the second and third ribs. This is the preferred method of puncture, as axillary vein appears to lie across the rib cage at this site in a relatively constant fashion.21

• Ultrasound-guided: Use the ultrasound probe in a sterile cover to obtain an image of both the axillary vein and artery. Position the needle at the point where the probe meets the skin and advance under direct observation.

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Fig. 8 Fluoroscopic-guided axillary vein puncture.

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Fig. 8 Fluoroscopic-guided axillary vein puncture.

Indications

• Placement of pacemaker leads, defibrillation leads

• Venous access for placing temporary pacing wire, pulmonary catheters

• Placement of dialysis catheters

Contraindications

• Absolute contraindications

  • ○ Ipsilateral lymphedema, cellulitis, radical lymph node resection

  • ○ Ipsilateral venous system occlusion

• Relative contraindications

  • ○ Ipsilateral mastectomy

  • ○ Ipsilateral arteriovenous fistula

Patient Position and Preparation

• The patient lies supine, Trendelenburg's position if feasible.

• A rolled towel between the scapula would push the lateral ends of the clavicle posteriorly and give better access to the axillary vein.

• Local anesthesia with 1% lidocaine is usually sufficient.

Complications

Relatively less in experienced hands.

• ○ Pneumothorax

• ○ Hemothorax

• ○ Arterial injury

• ○ Arteriovenous fistula

• ○ Hematoma, bleeding, thrombus, and infection

Cannulation of the axillary vein by infraclavicular approach is a safe and attractive option as the site is clean and comfortable for the patient, lesser risk of pneumothorax, hemothorax, and chylothorax. In the event of inadvertent arterial puncture, external pressure can be safely applied with a more lateral approach.

Anatomy

External jugular vein begins at the angle of the mandible and runs obliquely across the sternocleidomastoid up to the middle of the clavicle (Fig. 9). It is covered by platysma and superficial fascia and is separated from the sternocleidomastoid by the deep fascia.

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Fig. 9 (A) Anatomy of extrajugular vein. (B) Surface marking of extrajugular vein.

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Fig. 9 (A) Anatomy of extrajugular vein. (B) Surface marking of extrajugular vein.

Patient Position and Preparation

Trendelenburg's position with the head slightly is tilted to the opposite side. Light pressure above the clavicle helps engorge the EJV and facilitate cannulation.22

Technique

• The site of puncture should be proximal, far away from the clavicle.

• Apply sterile drape (2% chlorhexidine or 70% alcohol).

• Infiltrate 0.5 to 1.0 mL of lidocaine to raise a wheal at the site.

• Stabilize the skin over the desired puncture site with the nondominant thumb and pierce the EJV at 10 to 25 degrees.

• Once blood appears in the chamber, the angle should be reduced to avoid puncture of the posterior wall of the vein. Advance the needle another 2 to 3 mm into the vessel.

• The catheter is introduced directly over the needle or by Seldinger technique. The use of the Seldinger J-wire has increased successful cannulation of the EJV from 50 to 79–90%.

• In case of failed cannulation, withdraw the needle up to the skin and retry.

• In case of swelling suggestive of hematoma, withdraw the needle and apply compression for 5 minutes (Fig. 10).

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Fig. 10 EJV puncture.

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Fig. 10 EJV puncture.

Causes of cannulation failures are:

• Difficult passage of the J-wire through the EJV-SCV junction into the thorax

• Collapse of the vein

• Inadequate skin traction

• Incorrect positioning and incorrect angle of penetration

Ultrasound guidance facilitates peripheral venous placement in patients with difficult IV access when veins are not readily visualized or palpable.

Indications

Venous access is done in an emergency for the administration of fluids. Medications are used during resuscitation.

Contraindications

There are no absolute contraindications. Vesicant solutions, irritant solutions such as sclerosing agent, and high-pressure contrast agents should be avoided being injected into the EJV.

Complications

• Thrombophlebitis—pain, inflammation, and infection

The catheter should be replaced every 3 to 4 days routinely or earlier in case of thrombophlebitis.

• Inadvertent arterial puncture

Absolute Contraindications

• Overlying skin infection

• Thrombophlebitis

• Vein thrombosis

Relative Contraindications

Relative contraindications are lack of approachability to the vein.

Advantages

Safe procedure. No serious complications.

Disadvantages

• Anatomical factors (acute angle between the EJV and SV; the presence of valves; constriction of the EJV) can make cannulation difficult.24

• Variability in the course (EJV terminates into a venous plexus in 4%)22 could prove to be challenging.

• EJV size is inversely proportional to the IJV and could pose a problem for sizing of the device.25

After three unsuccessful attempts, another site should be pursued. Kato et al have suggested that EJV cannulation under CT venography guided is worth the efforts in moribund patients.

Technical success varies from 73 to 86%.26

Antecubital Access

Cardiac catheterization and fluoroscopy originated with Dr. Werner Forssmann's self-catheterization via the antecubital vein. Upper extremity venous access for right heart cauterization is a safe procedure that scores over traditional femoral or internal jugular access. According to a retrospective study by Shah et al,27 success rates were 91% for antecubital venous access and 96% for proximal venous access for a right heart catheterization. The antecubital access group had a 0% complication rate, whereas the proximal venous access group had 3% complication rate that included inadvertent arterial puncture and hematoma formation.

Advantages

• Shorter fluoroscopy time

• Decreased radiation dose

• Fewer access site complications

• Decreased time to ambulation

Most procedures through the antecubital access can be performed with only local anesthesia or mild sedation, obviating the need for higher levels of anesthesia. Upper extremity venous access can be a useful access modality for catheterization in both children and adults, especially in pediatric catheterization. This access mode facilitates diagnostic catheterization and quicker recovery times as well as complex interventions.

The antecubital fossa and proximal arm contain three major accessible veins:

• Cephalic vein

• Basilic vein

• Brachial vein

These veins are large and can be easily cannulated. Ultrasound-guided puncture is advocated to avoid arterial and nerve injury.

Anatomy

Cephalic and basilic veins are superficial veins formed from the dorsal venous network on the dorsum of the hand and ultimately drain into the axillary vein. Whereas the cephalic vein runs on the radial aspect of the arm, the basilic vein is along the ulnar aspect. The median cubital vein connects both in the cubital fossa.

The brachial vein is the major deep vein of the arm. It is formed by the joining of radial and ulnar veins in the cubital fossa and ends at the lower end of Teres major muscle (at the lateral border of the scapula on an anteroposterior chest X-ray), where it continues as an axillary vein (Fig. 11).

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Fig. 11 Anatomy of venous access of upper limb.

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Fig. 11 Anatomy of venous access of upper limb.

Surface Anatomy

The cephalic vein begins at the anatomical snuff box, runs across the distal radius to the ventral aspect of the forearm, and ascends on the lateral side of the arm. It pierces the clavipectoral fascia and empties into the axillary vein.

The basilic vein begins at the ulnar side of the wrist runs along the ulnar aspect of the forearm ventrally till the elbow. Above the elbow, it runs medial to the biceps and perforates the deep fascia in the midarm to joins the brachial vein.

Regarding the venous anatomy of the arm, medial is better than lateral and higher is better than lower. Medial position of the brachial vein makes it more suitable as access than the cephalic vein, which forms an acute angle with the subclavian that is difficult to negotiate. The vein becomes larger as we go higher in the arm, making it more suitable for larger devices.

Technique for Brachial Vein Cannulation28 29

Popliteal Vein

Anatomy

Popliteal vein is formed from the anterior and posterior tibial veins at the lower border of popliteal muscle (the lower aspect of the posterior knee), ascends through the popliteal fossa, and passes through the opening in adductor Magnus to continue as the femoral vein. It always lies between the popliteal artery and the tibial nerve. Distally it is medial to the artery, between the two heads of gastronomes, it is posterior (superficial) to the artery, and proximally it is posterior-lateral to it (Fig. 13).

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Fig. 13 Surface marking of popliteal vein.

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Fig. 13 Surface marking of popliteal vein.

Tibial Veins

Anterior and posterior tibial veins are deep veins of the lower limb, occur in pairs, and accompany the corresponding artery.

Anatomy

The posterior tibial veins receive blood from medial and lateral plantar veins and drain the plantar surface of the foot and posterior compartment of the leg. It ascends behind the tibia to join the popliteal vein at the lower aspect of the posterior knee. It is joined by the peroneal vein that runs along the posteromedial aspect of the fibula. The anterior tibial veins run along with the anterior compartment of the leg between the tibia and fibula before joining the posterior tibial vein (Fig. 14).

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Fig. 14 Surface anatomy of anterior tibial vein.

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Fig. 14 Surface anatomy of anterior tibial vein.

Small Saphenous Vein

This superficial vein is often used for venous access in infants and children.

Anatomy

Small saphenous vein is found half to one finger breadth lateral (anterior) to the lateral malleolus (Fig. 15).

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Fig. 15 Venous puncture site for small saphenous vein.

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Fig. 15 Venous puncture site for small saphenous vein.